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Jelen LA, McShane R, Young AH. Guidelines for ketamine use in clinical psychiatry practice. BJPsych Open 2024; 10:e107. [PMID: 38725375 PMCID: PMC11094435 DOI: 10.1192/bjo.2024.62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/20/2024] [Accepted: 03/31/2024] [Indexed: 05/18/2024] Open
Abstract
In this editorial, we emphasise the efficacy and challenges of using ketamine in treatment-resistant depression. We highlight the need for comprehensive evidence-based guidelines to manage the use of both licensed and off-licence ketamine formulations and discuss recent efforts by Beaglehole et al to develop ketamine guidelines in New Zealand. We finally advocate for national registries to monitor ketamine therapy, ensuring its responsible and effective use in the management of depression.
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Affiliation(s)
- Luke A. Jelen
- The Maudsley Hospital, London, UK; and Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK
| | - Rupert McShane
- Department of Psychiatry, Oxford University, UK; and Oxfordshire ECT and Ketamine Service, Oxford, UK
| | - Allan H. Young
- Centre for Affective Disorders, Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK
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Potter CM, Peters M, Cundell M, McShane R, Fitzpatrick R. Living well while providing support: validation of LTCQ-Carer for assessing informal carers' quality of life. Qual Life Res 2023; 32:3507-3520. [PMID: 37530960 PMCID: PMC10624753 DOI: 10.1007/s11136-023-03485-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2023] [Indexed: 08/03/2023]
Abstract
PURPOSE Despite international policies to support the health and wellbeing of informal (family) caregivers, there is no consensus on how to evaluate the effectiveness of carer support. We aimed to develop and validate a new quality-of-life measure for carers (LTCQ-Carer) and to assess its potential for use within a clinical pathway. METHODS Psychometric properties of LTCQ-Carer were tested through cognitive interviews (qualitative phase) and a pilot survey (quantitative phase). Participants were family caregivers of people recently diagnosed with mild cognitive impairment (MCI) or dementia, recruited through one of 14 memory clinics in south-east England. They self-completed the new measure and comparative existing measures (EQ-5D, ASCOT-Carer). Ongoing feedback from memory clinic staff on potential use of LTCQ-Carer was collected. RESULTS Interview participants (n = 10) found all draft items of LTCQ-Carer relevant and prompted inclusion of a new item on 'time to yourself'. Responses from survey participants (n = 107) indicated acceptability (low missing data), high internal reliability (Cronbach's α = 0.95), and a general construct (single factor loadings 0.43-0.86 for all items). Observation of predicted associations with EQ-5D and ASCOT-Carer supported construct validity. Responsiveness requires further testing as evidence was inconclusive. Clinical staff feedback on potential use was positive. CONCLUSION LTCQ-Carer is a valid new measure for assessing family caregivers' quality of life across broad health and social care domains, expanding the range of high-quality tools for evaluating carer support. When used concurrently with patient assessment, it could highlight carer needs and prompt appropriate family support at the earliest point in the clinical pathway.
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Affiliation(s)
- Caroline M Potter
- Health Services Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
- Applied Research Collaboration Oxford and Thames Valley (NIHR ARC OxTV), National Institute for Health and Care Research, Oxford Health NHS Foundation Trust, Oxford, UK.
- Oxford Institute of Population Ageing, University of Oxford, Oxford, UK.
| | - Michele Peters
- Health Services Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Applied Research Collaboration Oxford and Thames Valley (NIHR ARC OxTV), National Institute for Health and Care Research, Oxford Health NHS Foundation Trust, Oxford, UK
| | | | | | - Ray Fitzpatrick
- Health Services Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Applied Research Collaboration Oxford and Thames Valley (NIHR ARC OxTV), National Institute for Health and Care Research, Oxford Health NHS Foundation Trust, Oxford, UK
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Lindner JR, Ebrahimi A, Kochanowicz JF, Szczupak J, Paris T, Abdelsamie A, Parikh SV, McShane R, Costi S. Preliminary Evaluation of a Web-Based International Journal Club for Ketamine in Psychiatric Disorders: Cross-Sectional Survey Study. JMIR Med Educ 2023; 9:e46158. [PMID: 37910164 PMCID: PMC10652200 DOI: 10.2196/46158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 07/27/2023] [Accepted: 09/28/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND The use of novel rapid-acting antidepressants for psychiatric disorders is expanding. The web-based Ketamine and Related Compounds International Journal Club (KIJC) was created during the COVID-19 pandemic by UK academic psychiatrists and trainees for interested global professionals to discuss papers related to the topic of ketamine for the treatment of psychiatric disorders. The KIJC aimed to facilitate bidirectional discussions, sharing of ideas, and networking among participants. OBJECTIVE The aim of this study is a preliminary evaluation of the journal club's format for satisfaction and impact after the first year of running. METHODS A website, email, and word of mouth were used for recruitment. The journal club was held twice per month using videoconferencing software in 3 parts: a 20-minute presentation, a 15-minute chaired question and answer session, and a 25-minute informal discussion with participants' cameras on. The first 2 parts were recorded and uploaded to the website alongside links to the corresponding papers. In total, 24 speakers presented from 8 countries, typically within 2 (SD 2) months of publication. The average attendance was 51 (SD 20) audience members, and there were 63 (SD 50) views of each subsequent recording. Two anonymous web-based cross-sectional surveys were conducted from November 2021 to February 2022, one for speakers and another for audience members, separately. Various survey statements, 14 for speakers and 12 for the audience, were categorized according to satisfaction and impact, alongside obtaining participants' primary career roles and requesting optional written feedback. Responses were compared between both groups and analyzed, including an inductive thematic analysis and a summary of lessons learned. RESULTS A total of 30 survey responses were obtained, demonstrating overall agreement with the statements. In total, 12 (50%) out of 24 speakers and 18 (35%) out of an average of 51 (SD 20) audience members regarded the journal club's format as satisfying and impactful. The majority (26/30, 87%) of respondents identified as clinicians (9/30, 30%), researchers (9/30, 30%), and clinician-researchers (8/30, 27%). Additionally, 11 (37%) of the 30 respondents also provided optional written feedback: 3 (10%) speakers and 8 (27%) audience members. From the written feedback, 5 main themes were derived: engagement with the journal club, desire for active participation, improving the platform, positive learning experiences, and suggestions for future sessions. CONCLUSIONS The journal club successfully reached its intended audience and developed into a web-based community. The majority of the participants were satisfied with the format and found it impactful. Overall, the journal club appears to be a valuable tool for knowledge sharing and community building in the field of ketamine use for the treatment of psychiatric disorders. A larger sample size and additional testing methods are required to support the generalizability of the journal club's format.
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Affiliation(s)
- Jacek R Lindner
- Interventional Psychiatry Service, Warneford Hospital, Oxford Health NHS Foundation Trust, Oxford, United Kingdom
| | - Ashkan Ebrahimi
- Medicine Program, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Justyna Szczupak
- South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Timothy Paris
- Warneford Hospital, Oxford Health NHS Foundation Trust, Oxford, United Kingdom
| | - Ahmed Abdelsamie
- South London and Maudsley NHS Foundation Trust, London, United Kingdom
- King's College London, London, United Kingdom
| | - Sagar V Parikh
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Rupert McShane
- Warneford Hospital, Oxford Health NHS Foundation Trust, Oxford, United Kingdom
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - Sara Costi
- Warneford Hospital, Oxford Health NHS Foundation Trust, Oxford, United Kingdom
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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Affiliation(s)
- Rupert McShane
- From Oxford Health NHS Foundation Trust and the Department of Psychiatry, University of Oxford, Oxford, United Kingdom
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Sen A, Mary A, Tai XY, Mura S, Galloway J, Hallam A, Frangou E, Love S, Chan J, Koychev IG, Geddes J, Manohar S, Symmonds M, VanDerPutt R, Thompson S, McShane R, Husain M. ILiAD trial of levetiracetam. Alzheimers Dement 2022. [DOI: 10.1002/alz.059599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Arjune Sen
- University of Oxford Oxford United Kingdom
| | - Akinola Mary
- Oxford University Hospitals NHS Foundation Trust Oxford United Kingdom
| | | | - Sergio Mura
- Oxford University Hospitals NHS Foundation Trust Oxford United Kingdom
| | | | - Angela Hallam
- St Mary’s Pharmaceutical Unit Cardiff United Kingdom
| | | | - Sharon Love
- University College London London United Kingdom
| | - Jane Chan
- Freeline Therapeutics London United Kingdom
| | - Ivan G Koychev
- Department of Psychiatry, University of Oxford Oxford United Kingdom
| | | | | | | | | | - Sian Thompson
- Oxford University Hospitals NHS Foundation Trust Oxford United Kingdom
| | | | - Masud Husain
- Department of Experimental Psychology, University of Oxford, UK Oxford United Kingdom
- Nuffield Department of Clinical Neurosciences, University of Oxford Oxford United Kingdom
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Bayes A, Short B, Zarate CA, Park L, Murrough JW, McLoughlin DM, Riva-Posse P, Schoevers R, Veraart J, Parikh S, Glue P, Fam J, McShane R, Galvez V, Martin D, Tor PC, Brunoni A, Loo CK. The Ketamine Side Effect Tool (KSET): A comprehensive measurement-based safety tool for ketamine treatment in psychiatry. J Affect Disord 2022; 308:44-46. [PMID: 35405177 PMCID: PMC9133168 DOI: 10.1016/j.jad.2022.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 03/01/2022] [Accepted: 04/06/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES On a background of the rapidly expanding clinical use of ketamine and esketamine for treatment of depression and other conditions, we examined safety monitoring, seeking to identify knowledge gaps relevant to clinical practice. METHODS An international group of psychiatrists discussed the issue of safety of ketamine and esketamine and came to a consensus on key safety gaps. RESULTS There is no standard safety monitoring for off-label generic ketamine. For intranasal esketamine, each jurisdiction providing regulatory approval may specify monitoring. Treatment is often provided beyond the period for which safety has been demonstrated, with no agreed framework for monitoring of longer term side effects for either generic ketamine or intranasal esketamine. LIMITATIONS The KSET has established face and content validity, however it has not been validated against other measures of safety. CONCLUSIONS We recommend the Ketamine Side Effect Tool (KSET) as a comprehensive safety monitoring tool for acute and longer term side effects.
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Affiliation(s)
- Adam Bayes
- Black Dog Institute, UNSW Sydney, Australia; School of Psychiatry, UNSW Sydney, Australia.
| | | | - Carlos A. Zarate
- Division of Intramural Research Program, National Institute of Mental Health, MD, United States
| | - Lawrence Park
- Division of Intramural Research Program, National Institute of Mental Health, MD, United States
| | - James W. Murrough
- Depression and Anxiety Centre for Discovery and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Declan M. McLoughlin
- Department of Psychiatry, Trinity College Institute of Neuroscience, Trinity College, Dublin, Ireland
| | - Patricio Riva-Posse
- Department of Psychiatry and Behavioral Sciences at Emory University, Atlanta, GA, United States
| | - Robert Schoevers
- The University Medical Center Groningen, Groningen, the Netherlands
| | - Jolien Veraart
- The University Medical Center Groningen, Groningen, the Netherlands
| | - Sagar Parikh
- Department of Psychiatry, University of Michigan, MI, United States
| | - Paul Glue
- University of Otago, Dunedin, New Zealand
| | - Johnson Fam
- Department of Psychological Medicine, National University Hospital, Singapore,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Rupert McShane
- Department of Psychiatry, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | - Veronica Galvez
- Corporacio Sanitaria Parc Tauli, Universitat Autonoma de Barcelona, I3PT, Institut d’Investigacio i Innovacio Parc Tauli, Sabadell, Barcelona, Spain
| | | | | | - Andre Brunoni
- Laboratory of Neurosciences (LIM-27), Institute of Psychiatry, Hospital das Clínicas da Faculdade de Medicina da USP, Brazil
| | - Colleen K. Loo
- Black Dog Institute, UNSW Sydney, Australia,School of Psychiatry, UNSW Sydney, Australia
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Dean RL, Marquardt T, Hurducas C, Spyridi S, Barnes A, Smith R, Cowen PJ, McShane R, Hawton K, Malhi GS, Geddes J, Cipriani A. Ketamine and other glutamate receptor modulators for depression in adults with bipolar disorder. Cochrane Database Syst Rev 2021; 10:CD011611. [PMID: 34623633 PMCID: PMC8499740 DOI: 10.1002/14651858.cd011611.pub3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Glutamergic system dysfunction has been implicated in the pathophysiology of bipolar depression. This is an update of the 2015 Cochrane Review for the use of glutamate receptor modulators for depression in bipolar disorder. OBJECTIVES 1. To assess the effects of ketamine and other glutamate receptor modulators in alleviating the acute symptoms of depression in people with bipolar disorder. 2. To review the acceptability of ketamine and other glutamate receptor modulators in people with bipolar disorder who are experiencing depressive symptoms. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Embase and PsycINFO all years to July 2020. We did not apply any restrictions to date, language or publication status. SELECTION CRITERIA RCTs comparing ketamine or other glutamate receptor modulators with other active psychotropic drugs or saline placebo in adults with bipolar depression. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, assessed trial quality and extracted data. Primary outcomes were response rate and adverse events. Secondary outcomes included remission rate, depression severity change scores, suicidality, cognition, quality of life, and dropout rate. The GRADE framework was used to assess the certainty of the evidence. MAIN RESULTS Ten studies (647 participants) were included in this review (an additional five studies compared to the 2015 review). There were no additional studies added to the comparisons identified in the 2015 Cochrane review on ketamine, memantine and cytidine versus placebo. However, three new comparisons were found: ketamine versus midazolam, N-acetylcysteine versus placebo, and riluzole versus placebo. The glutamate receptor modulators studied were ketamine (three trials), memantine (two), cytidine (one), N-acetylcysteine (three), and riluzole (one). Eight of these studies were placebo-controlled and two-armed. In seven trials the glutamate receptor modulators had been used as add-on drugs to mood stabilisers. Only one trial compared ketamine with an active comparator, midazolam. The treatment period ranged from a single intravenous administration (all ketamine studies), to repeated administration for riluzole, memantine, cytidine, and N-acetylcysteine (with a follow-up of eight weeks, 8 to 12 weeks, 12 weeks, and 16 to 20 weeks, respectively). Six of the studies included sites in the USA, one in Taiwan, one in Denmark, one in Australia, and in one study the location was unclear. All participants had a primary diagnosis of bipolar disorder and were experiencing an acute bipolar depressive episode, diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders fourth edition (IV) or fourth edition text revision (IV-TR). Among all glutamate receptor modulators included in this review, only ketamine appeared to be more efficacious than placebo 24 hours after infusion for response rate (odds ratio (OR) 11.61, 95% confidence interval (CI) 1.25 to 107.74; P = 0.03; participants = 33; studies = 2; I² = 0%, low-certainty evidence). Ketamine seemed to be more effective in reducing depression rating scale scores (MD -11.81, 95% CI -20.01 to -3.61; P = 0.005; participants = 32; studies = 2; I2 = 0%, very low-certainty evidence). There was no evidence of ketamine's efficacy in producing remission over placebo at 24 hours (OR 5.16, 95% CI 0.51 to 52.30; P = 0.72; participants = 33; studies = 2; I2 = 0%, very low-certainty evidence). Evidence on response, remission or depression rating scale scores between ketamine and midazolam was uncertain at 24 hours due to very low-certainty evidence (OR 3.20, 95% CI 0.23 to 45.19). In the one trial assessing ketamine and midazolam, there were no dropouts due to adverse effects or for any reason (very low-certainty evidence). Placebo may have been more effective than N-acetylcysteine in reducing depression rating scale scores at three months, although this was based on very low-certainty evidence (MD 1.28, 95% CI 0.24 to 2.31; participants = 58; studies = 2). Very uncertain evidence found no difference in response at three months (OR 0.82, 95% CI 0.32 to 2.14; participants = 69; studies = 2; very low-certainty evidence). No data were available for remission or acceptability. Extremely limited data were available for riluzole vs placebo, finding only very-low certainty evidence of no difference in dropout rates (OR 2.00, 95% CI 0.31 to 12.84; P = 0.46; participants = 19; studies = 1; I2 = 0%). AUTHORS' CONCLUSIONS It is difficult to draw reliable conclusions from this review due to the certainty of the evidence being low to very low, and the relatively small amount of data usable for analysis in bipolar disorder, which is considerably less than the information available for unipolar depression. Nevertheless, we found uncertain evidence in favour of a single intravenous dose of ketamine (as add-on therapy to mood stabilisers) over placebo in terms of response rate up to 24 hours, however ketamine did not show any better efficacy for remission in bipolar depression. Even though ketamine has the potential to have a rapid and transient antidepressant effect, the efficacy of a single intravenous dose may be limited. We did not find conclusive evidence on adverse events with ketamine, and there was insufficient evidence to draw meaningful conclusions for the remaining glutamate receptor modulators. However, ketamine's psychotomimetic effects (such as delusions or delirium) may have compromised study blinding in some studies, and so we cannot rule out the potential bias introduced by inadequate blinding procedures. To draw more robust conclusions, further methodologically sound RCTs (with adequate blinding) are needed to explore different modes of administration of ketamine, and to study different methods of sustaining antidepressant response, such as repeated administrations.
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Affiliation(s)
| | | | | | - Styliani Spyridi
- Department of Rehabilitation Sciences, Faculty of Health Sciences, Cyprus University of Technology, Lemesos, Cyprus
| | | | | | - Philip J Cowen
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Rupert McShane
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Keith Hawton
- Centre for Suicide Research, University Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - Gin S Malhi
- Discipline of Psychiatry, Northern Clinical School, University of Sydney, Sydney, Australia
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Dean RL, Hurducas C, Hawton K, Spyridi S, Cowen PJ, Hollingsworth S, Marquardt T, Barnes A, Smith R, McShane R, Turner EH, Cipriani A. Ketamine and other glutamate receptor modulators for depression in adults with unipolar major depressive disorder. Cochrane Database Syst Rev 2021; 9:CD011612. [PMID: 34510411 PMCID: PMC8434915 DOI: 10.1002/14651858.cd011612.pub3] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Many studies have recently been conducted to assess the antidepressant efficacy of glutamate modification in mood disorders. This is an update of a review first published in 2015 focusing on the use of glutamate receptor modulators in unipolar depression. OBJECTIVES To assess the effects - and review the acceptability and tolerability - of ketamine and other glutamate receptor modulators in alleviating the acute symptoms of depression in people with unipolar major depressive disorder. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Embase and PsycINFO all years to July 2020. We did not apply any restrictions to date, language or publication status. SELECTION CRITERIA Double- or single-blinded randomised controlled trials (RCTs) comparing ketamine, memantine, esketamine or other glutamate receptor modulators with placebo (pill or saline infusion), other active psychotropic drugs, or electroconvulsive therapy (ECT) in adults with unipolar major depression. DATA COLLECTION AND ANALYSIS Three review authors independently identified studies, assessed trial quality and extracted data. The primary outcomes were response rate (50% reduction on a standardised rating scale) and adverse events. We decided a priori to measure the efficacy outcomes at different time points and run sensitivity/subgroup analyses. Risk of bias was assessed using the Cochrane tool, and certainty of the evidence was assessed using GRADE. MAIN RESULTS Thirty-one new studies were identified for inclusion in this updated review. Overall, we included 64 studies (5299 participants) on ketamine (31 trials), esketamine (9), memantine (5), lanicemine (4), D-cycloserine (2), Org26576 (2), riluzole (2), atomoxetine (1), basimglurant (1), citicoline (1), CP-101,606 (1), decoglurant (1), MK-0657 (1), N-acetylcysteine (1), rapastinel (1), and sarcosine (1). Forty-eight studies were placebo-controlled, and 48 were two-arm studies. The majority of trials defined an inclusion criterion for the severity of depressive symptoms at baseline: 29 at least moderate depression; 17 severe depression; and five mild-to-moderate depression. Nineteen studies recruited only patients with treatment-resistant depression, defined as inadequate response to at least two antidepressants. The majority of studies investigating ketamine administered as a single dose, whilst all of the included esketamine studies used a multiple dose regimen (most frequently twice a week for four weeks). Most studies looking at ketamine used intravenous administration, whilst the majority of esketamine trials used intranasal routes. The evidence suggests that ketamine may result in an increase in response and remission compared with placebo at 24 hours odds ratio (OR) 3.94, 95% confidence interval (CI) 1.54 to 10.10; n = 185, studies = 7, very low-certainty evidence). Ketamine may reduce depression rating scale scores over placebo at 24 hours, but the evidence is very uncertain (standardised mean difference (SMD) -0.87, 95% CI -1.26 to -0.48; n = 231, studies = 8, very low-certainty evidence). There was no difference in the number of participants assigned to ketamine or placebo who dropped out for any reason (OR 1.25, 95% CI 0.19 to 8.28; n = 201, studies = 6, very low-certainty evidence). When compared with midazolam, the evidence showed that ketamine increases remission rates at 24 hours (OR 2.21, 95% CI 0.67 to 7.32; n = 122,studies = 2, low-certainty evidence). The evidence is very uncertain about the response efficacy of ketamine at 24 hours in comparison with midazolam, and its ability to reduce depression rating scale scores at the same time point (OR 2.48, 95% CI 1.00 to 6.18; n = 296, studies = 4,very low-certainty evidence). There was no difference in the number of participants who dropped out of studies for any reason between ketamine and placebo (OR 0.33, 95% CI 0.05 to 2.09; n = 72, studies = 1, low-certainty evidence). Esketamine treatment likely results in a large increase in participants achieving remission at 24 hours compared with placebo (OR 2.74, 95% CI 1.71 to 4.40; n = 894, studies = 5, moderate-certainty evidence). Esketamine probably results in decreases in depression rating scale scores at 24 hours compared with placebo (SMD -0.31, 95% CI -0.45 to -0.17; n = 824, studies = 4, moderate-certainty evidence). Our findings show that esketamine increased response rates, although this evidence is uncertain (OR 2.11, 95% CI 1.20 to 3.68; n = 1071, studies = 5, low-certainty evidence). There was no evidence that participants assigned to esketamine treatment dropped out of trials more frequently than those assigned to placebo for any reason (OR 1.58, 95% CI 0.92 to 2.73; n = 773, studies = 4,moderate-certainty evidence). We found very little evidence for the remaining glutamate receptor modulators. We rated the risk of bias as low or unclear for most domains, though lack of detail regarding masking of treatment in the studies reduced our certainty in the effect for all outcomes. AUTHORS' CONCLUSIONS Our findings show that ketamine and esketamine may be more efficacious than placebo at 24 hours. How these findings translate into clinical practice, however, is not entirely clear. The evidence for use of the remaining glutamate receptor modulators is limited as very few trials were included in the meta-analyses for each comparison and the majority of comparisons included only one study. Long term non-inferiority RCTs comparing repeated ketamine and esketamine, and rigorous real-world monitoring are needed to establish comprehensive data on safety and efficacy.
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Affiliation(s)
| | | | - Keith Hawton
- Centre for Suicide Research, Department of Psychiatry, University of Oxford, Oxford, UK
| | - Styliani Spyridi
- Department of Rehabilitation Sciences, Faculty of Health Sciences, Cyprus University of Technology, Lemesos, Cyprus
| | - Philip J Cowen
- Department of Psychiatry, University of Oxford, Oxford, UK
| | | | | | | | | | - Rupert McShane
- Oxford Health NHS Foundation Trust, Oxford, UK
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Erick H Turner
- Portland Veterans Affairs Medical Center, P3MHDC, Portland, USA
- Department of Psychiatry, Oregon Health & Science University, Portland, Oregon, USA
| | - Andrea Cipriani
- Oxford Health NHS Foundation Trust, Oxford, UK
- Department of Psychiatry, University of Oxford, Oxford, UK
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Sen A, Akinola M, Tai XY, Symmonds M, Davis Jones G, Mura S, Galloway J, Hallam A, Chan JYC, Koychev I, Butler C, Geddes J, Van Der Putt R, Thompson S, Manohar SG, Frangou E, Love S, McShane R, Husain M. An Investigation of Levetiracetam in Alzheimer's Disease (ILiAD): a double-blind, placebo-controlled, randomised crossover proof of concept study. Trials 2021; 22:508. [PMID: 34332638 PMCID: PMC8325256 DOI: 10.1186/s13063-021-05404-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 06/27/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Although Alzheimer's disease affects around 800,000 people in the UK and costs almost £23 billion per year, currently licenced treatments only offer modest benefit at best. Seizures, which are more common in patients with Alzheimer's disease than age matched controls, may contribute to the loss of nerve cells and abnormal brain discharges can disrupt cognition. This aberrant electrical activity may therefore present potentially important drug targets. The anti-seizure medication levetiracetam can reduce abnormal cortical discharges and reverse memory deficits in a mouse model of Alzheimer's disease. Levetiracetam has also been shown to improve memory difficulties in patients with mild cognitive impairment, a precursor to Alzheimer's disease. Clinical use of levetiracetam is well-established in treatment of epilepsy and extensive safety data are available. Levetiracetam thus has the potential to provide safe and efficacious treatment to help with memory difficulties in Alzheimer's disease. METHODS The proposed project is a proof of concept study to test whether levetiracetam can help cognitive function in people with dementia. We plan to recruit thirty patients with mild to moderate Alzheimer's disease with no history of previous seizures or other significant co-morbidity. Participants will be allocated to a double-blind placebo-controlled crossover trial that tests levetiracetam against placebo. Standardised scales to assess cognition and a computer-based touchscreen test that we have developed to better detect subtle improvements in hippocampal function will be used to measure changes in memory. All participants will have an electroencephalogram (EEG) at baseline. The primary outcome measure is a change in the computer-based touchscreen cognitive task while secondary outcomes include the effect of levetiracetam on mood, quality of life and modelling of the EEG, including time series measures and feature-based analysis to see whether the effect of levetiracetam can be predicted. The effect of levetiracetam and placebo will be compared within a given patient using the paired t-test and the analysis of covariance adjusting for baseline values. DISCUSSION This is the first study to evaluate if an anti-seizure medication can offer meaningful benefit to patients with Alzheimer's disease. If this study demonstrates at least stabilisation of memory function and/or good tolerability, the next step will be to rapidly progress to a larger study to establish whether levetiracetam may be a useful and cost-effective treatment for patients with Alzheimer's disease. TRIAL REGISTRATION ClinicalTrials.gov NCT03489044 . Registered on April 5, 2018.
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Affiliation(s)
- Arjune Sen
- Oxford Epilepsy Research Group, NIHR Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK.
- Department of Neurology, John Radcliffe Hospital, Oxford, OX3 9DU, UK.
- Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford, OX3 9DU, UK.
| | - Mary Akinola
- Local Clinical Trials Network, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Xin You Tai
- Oxford Epilepsy Research Group, NIHR Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
- Department of Neurology, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Mkael Symmonds
- Oxford Epilepsy Research Group, NIHR Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
- Department of Clinical Neurophysiology, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Gabriel Davis Jones
- Oxford Epilepsy Research Group, NIHR Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
- Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford, OX3 9DU, UK
| | - Sergio Mura
- Clinical Trials Pharmacy, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | | | - Angela Hallam
- St Mary's Pharmaceutical Unit, Cardiff University, Cardiff, 20 Fieldway, Cardiff, CF14 4HY, UK
| | - Jane Y C Chan
- Freeline Therapeutics, King's Court, London Road, Stevenage, SG1 2NG, UK
- Translational Medicine, UCB Pharma, 208 Bath Road, Slough, SL1 3WE, UK
| | - Ivan Koychev
- Department of Psychiatry, University of Oxford, Oxford, OX3 7JX, UK
| | - Chris Butler
- Faculty of Medicine, Department of Brain Sciences, Imperial College, Sir Alexander Fleming Building, South Kensington Campus, London, SW7 2BU, UK
| | - John Geddes
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, OX3 7JX, UK
| | - Rohan Van Der Putt
- Memory and Cognition Research Delivery Team, Warneford Hospital, Warneford Lane, Headington, Oxford, OX3 7JX, UK
| | - Sian Thompson
- Department of Neurology, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Sanjay G Manohar
- Department of Neurology, John Radcliffe Hospital, Oxford, OX3 9DU, UK
- Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford, OX3 9DU, UK
| | - Eleni Frangou
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, Faculty of Pop Health Sciences, University College London, London, UK
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Oxford, OX3 7LD, UK
| | - Sharon Love
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, Faculty of Pop Health Sciences, University College London, London, UK
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Oxford, OX3 7LD, UK
| | - Rupert McShane
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, OX3 7JX, UK
| | - Masud Husain
- Oxford Epilepsy Research Group, NIHR Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
- Cognitive Neurology Research Group, Nuffield Dept Clinical Neurosciences & Department of Experimental Psychology, University of Oxford, West Wing, John Radcliffe Hospital, Oxford, OX3 9DU, UK
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Burton JK, Fearon P, Noel-Storr AH, McShane R, Stott DJ, Quinn TJ. Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) for the detection of dementia within a secondary care setting. Cochrane Database Syst Rev 2021; 7:CD010772. [PMID: 34278561 PMCID: PMC8406705 DOI: 10.1002/14651858.cd010772.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The diagnosis of dementia relies on the presence of new-onset cognitive impairment affecting an individual's functioning and activities of daily living. The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) is a questionnaire instrument, completed by a suitable 'informant' who knows the patient well, designed to assess change in functional performance secondary to cognitive change; it is used as a tool for identifying those who may have dementia. In secondary care there are two specific instances where patients may be assessed for the presence of dementia. These are in the general acute hospital setting, where opportunistic screening may be undertaken, or in specialist memory services where individuals have been referred due to perceived cognitive problems. To ensure an instrument is suitable for diagnostic use in these settings, its test accuracy must be established. OBJECTIVES To determine the accuracy of the informant-based questionnaire IQCODE for detection of dementia in a secondary care setting. SEARCH METHODS We searched the following sources on the 28th of January 2013: ALOIS (Cochrane Dementia and Cognitive Improvement Group), MEDLINE (Ovid SP), EMBASE (Ovid SP), PsycINFO (Ovid SP), BIOSIS Previews (Thomson Reuters Web of Science), Web of Science Core Collection (includes Conference Proceedings Citation Index) (Thomson Reuters Web of Science), CINAHL (EBSCOhost) and LILACS (BIREME). We also searched sources specific to diagnostic test accuracy: MEDION (Universities of Maastricht and Leuven); DARE (Database of Abstracts of Reviews of Effects - via the Cochrane Library); HTA Database (Health Technology Assessment Database via the Cochrane Library) and ARIF (Birmingham University). We also checked reference lists of relevant studies and reviews, used searches of known relevant studies in PubMed to track related articles, and contacted research groups conducting work on IQCODE for dementia diagnosis to try to find additional studies. We developed a sensitive search strategy; search terms were designed to cover key concepts using several different approaches run in parallel and included terms relating to cognitive tests, cognitive screening and dementia. We used standardised database subject headings such as MeSH terms (in MEDLINE) and other standardised headings (controlled vocabulary) in other databases, as appropriate. SELECTION CRITERIA We selected those studies performed in secondary-care settings, which included (not necessarily exclusively) IQCODE to assess for the presence of dementia and where dementia diagnosis was confirmed with clinical assessment. For the 'secondary care' setting we included all studies which assessed patients in hospital (e.g. acute unscheduled admissions, referrals to specialist geriatric assessment services etc.) and those referred for specialist 'memory' assessment, typically in psychogeriatric services. DATA COLLECTION AND ANALYSIS We screened all titles generated by electronic database searches, and reviewed abstracts of all potentially relevant studies. Two independent assessors checked full papers for eligibility and extracted data. We determined quality assessment (risk of bias and applicability) using the QUADAS-2 tool, and reporting quality using the STARD tool. MAIN RESULTS From 72 papers describing IQCODE test accuracy, we included 13 papers, representing data from 2745 individuals (n = 1413 (51%) with dementia). Pooled analysis of all studies using data presented closest to a cut-off of 3.3 indicated that sensitivity was 0.91 (95% CI 0.86 to 0.94); specificity 0.66 (95% CI 0.56 to 0.75); the positive likelihood ratio was 2.7 (95% CI 2.0 to 3.6) and the negative likelihood ratio was 0.14 (95% CI 0.09 to 0.22). There was a statistically significant difference in test accuracy between the general hospital setting and the specialist memory setting (P = 0.019), suggesting that IQCODE performs better in a 'general' setting. We found no significant differences in the test accuracy of the short (16-item) versus the 26-item IQCODE, or in the language of administration. There was significant heterogeneity in the included studies, including a highly varied prevalence of dementia (10.5% to 87.4%). Across the included papers there was substantial potential for bias, particularly around sampling of included participants and selection criteria, which may limit generalisability. There was also evidence of suboptimal reporting, particularly around disease severity and handling indeterminate results, which are important if considering use in clinical practice. AUTHORS' CONCLUSIONS The IQCODE can be used to identify older adults in the general hospital setting who are at risk of dementia and require specialist assessment; it is useful specifically for ruling out those without evidence of cognitive decline. The language of administration did not affect test accuracy, which supports the cross-cultural use of the tool. These findings are qualified by the significant heterogeneity, the potential for bias and suboptimal reporting found in the included studies.
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Affiliation(s)
- Jennifer K Burton
- Academic Geriatric Medicine, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Patricia Fearon
- Academic Section of Geriatric Medicine, University of Glasgow, Glasgow, UK
| | | | | | - David J Stott
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow , UK
| | - Terry J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Burton JK, Fearon P, Noel-Storr AH, McShane R, Stott DJ, Quinn TJ. Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) for the detection of dementia within a general practice (primary care) setting. Cochrane Database Syst Rev 2021; 7:CD010771. [PMID: 34278564 PMCID: PMC8406468 DOI: 10.1002/14651858.cd010771.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The IQCODE (Informant Questionnaire for Cognitive Decline in the Elderly) is a commonly used questionnaire based tool that uses collateral information to assess for cognitive decline and dementia. Brief tools that can be used for dementia "screening" or "triage" may have particular utility in primary care / general practice healthcare settings but only if they have suitable test accuracy. A synthesis of the available data regarding IQCODE accuracy in a primary care setting should help inform cognitive assessment strategies for clinical practice; research and policy. OBJECTIVES To determine the accuracy of the informant-based questionnaire IQCODE, for detection of dementia in a primary care setting. SEARCH METHODS A search was performed in the following sources on the 28th of January 2013: ALOIS (Cochrane Dementia and Cognitive Improvement Group), MEDLINE (Ovid SP), EMBASE (Ovid SP), PsycINFO (Ovid SP), BIOSIS (Ovid SP), ISI Web of Science and Conference Proceedings (ISI Web of Knowledge), CINHAL (EBSCOhost) and LILACs (BIREME). We also searched sources specific to diagnostic test accuracy: MEDION (Universities of Maastricht and Leuven); DARE (York University); HTA Database (Health Technology Assessments Database via The Cochrane Library) and ARIF (Birmingham University). We developed a sensitive search strategy; search terms were designed to cover key concepts using several different approaches run in parallel and included terms relating to cognitive tests, cognitive screening and dementia. We used standardized database subject headings such as MeSH terms (in MEDLINE) and other standardized headings (controlled vocabulary) in other databases, as appropriate. SELECTION CRITERIA We selected those studies performed in primary care settings, which included (not necessarily exclusively) IQCODE to assess for the presence of dementia and where dementia diagnosis was confirmed with clinical assessment. For the "primary care" setting, we included those healthcare settings where unselected patients, present for initial, non-specialist assessment of memory or non-memory related symptoms; often with a view to onward referral for more definitive assessment. DATA COLLECTION AND ANALYSIS We screened all titles generated by electronic database searches and abstracts of all potentially relevant studies were reviewed. Full papers were assessed for eligibility and data extracted by two independent assessors. Quality assessment (risk of bias and applicability) was determined using the QUADAS-2 tool. Reporting quality was determined using the STARDdem extension to the STARD tool. MAIN RESULTS From 71 papers describing IQCODE test accuracy, we included 1 paper, representing data from 230 individuals (n=16 [7%] with dementia). The paper described those patients consulting a primary care service who self-identified as Japanese-American. Dementia diagnosis was made using Benson & Cummings criteria and the IQCODE was recorded as part of a longer interview with the informant. IQCODE accuracy was assessed at various test thresholds, with a "trade-off" between sensitivity and specificity across these cutpoints. At an IQCODE threshold of 3.2 sensitivity: 100%, specificity: 76%; for IQCODE 3.7 sensitivity: 75%, specificity: 98%. Applying the QUADAS-2 assessments, the study was at high risk of bias in all categories. In particular degree of blinding was unclear and not all participants were included in the final analysis. AUTHORS' CONCLUSIONS It is not possible to give definitive guidance on the test accuracy of IQCODE for the diagnosis of dementia in a primary care setting based on the single study identified. We are surprised by the lack of research using the IQCODE in primary care as this is, arguably, the most appropriate setting for targeted case finding of those with undiagnosed dementia in order to maximise opportunities to intervene and provide support for the individual and their carers.
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Affiliation(s)
- Jennifer K Burton
- Academic Geriatric Medicine, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Patricia Fearon
- Academic Section of Geriatric Medicine, University of Glasgow, Glasgow, UK
| | | | - Rupert McShane
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - David J Stott
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow , UK
| | - Terry J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Quinn TJ, Fearon P, Noel-Storr AH, Young C, McShane R, Stott DJ. Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) for the detection of dementia within community dwelling populations. Cochrane Database Syst Rev 2021; 7:CD010079. [PMID: 34278562 PMCID: PMC8407460 DOI: 10.1002/14651858.cd010079.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Various tools exist for initial assessment of possible dementia with no consensus on the optimal assessment method. Instruments that use collateral sources to assess change in cognitive function over time may have particular utility. The most commonly used informant dementia assessment is the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). A synthesis of the available data regarding IQCODE accuracy will help inform cognitive assessment strategies for clinical practice, research and policy. OBJECTIVES Our primary obective was to determine the accuracy of the informant-based questionnaire IQCODE for detection of dementia within community dwelling populations. Our secondary objective was to describe the effect of heterogeneity on the summary estimates. We were particularly interested in the traditional 26-item scale versus the 16-item short form; and language of administration. We explored the effect of varying the threshold IQCODE score used to define 'test positivity'. SEARCH METHODS We searched the following sources on 28 January 2013: ALOIS (Cochrane Dementia and Cognitive Improvement Group), MEDLINE (OvidSP), EMBASE (OvidSP), PsycINFO (OvidSP), BIOSIS Previews (ISI Web of Knowledge), Web of Science with Conference Proceedings (ISI Web of Knowledge), LILACS (BIREME). We also searched sources relevant or specific to diagnostic test accuracy: MEDION (Universities of Maastrict and Leuven); DARE (York University); ARIF (Birmingham University). We used sensitive search terms based on MeSH terms and other controlled vocabulary. SELECTION CRITERIA We selected those studies performed in community settings that used (not necessarily exclusively) the IQCODE to assess for presence of dementia and, where dementia diagnosis was confirmed with clinical assessment. Our intention with limiting the search to a 'community' setting was to include those studies closest to population level assessment. Within our predefined community inclusion criteria, there were relevant papers that fulfilled our definition of community dwelling but represented a selected population, for example stroke survivors. We included these studies but performed sensitivity analyses to assess the effects of these less representative populations on the summary results. DATA COLLECTION AND ANALYSIS We screened all titles generated by the electronic database searches and abstracts of all potentially relevant studies were reviewed. Full papers were assessed for eligibility and data extracted by two independent assessors. For quality assessment (risk of bias and applicability) we used the QUADAS 2 tool. We included test accuracy data on the IQCODE used at predefined diagnostic thresholds. Where data allowed, we performed meta-analyses to calculate summary values of sensitivity and specificity with corresponding 95% confidence intervals (CIs). We pre-specified analyses to describe the effect of IQCODE format (traditional or short form) and language of administration for the IQCODE. MAIN RESULTS From 16,144 citations, 71 papers described IQCODE test accuracy. We included 10 papers (11 independent datasets) representing data from 2644 individuals (n = 379 (14%) with dementia). Using IQCODE cut-offs commonly employed in clinical practice (3.3, 3.4, 3.5, 3.6) the sensitivity and specificity of IQCODE for diagnosis of dementia across the studies were generally above 75%. Taking an IQCODE threshold of 3.3 (or closest available) the sensitivity was 0.80 (95% CI 0.75 to 0.85); specificity was 0.84 (95% CI 0.78 to 0.90); positive likelihood ratio was 5.2 (95% CI 3.7 to 7.5) and the negative likelihood ratio was 0.23 (95% CI 0.19 to 0.29). Comparative analysis suggested no significant difference in the test accuracy of the 16 and 26-item IQCODE tests and no significant difference in test accuracy by language of administration. There was little difference in sensitivity across our predefined diagnostic cut-points. There was substantial heterogeneity in the included studies. Sensitivity analyses removing potentially unrepresentative populations in these studies made little difference to the pooled data estimates. The majority of included papers had potential for bias, particularly around participant selection and sampling. The quality of reporting was suboptimal particularly regarding timing of assessments and descriptors of reproducibility and inter-observer variability. AUTHORS' CONCLUSIONS Published data suggest that if using the IQCODE for community dwelling older adults, the 16 item IQCODE may be preferable to the traditional scale due to lesser test burden and no obvious difference in accuracy. Although IQCODE test accuracy is in a range that many would consider 'reasonable', in the context of community or population settings the use of the IQCODE alone would result in substantial misdiagnosis and false reassurance. Across the included studies there were issues with heterogeneity, several potential biases and suboptimal reporting quality.
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Affiliation(s)
- Terry J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Patricia Fearon
- Academic Section of Geriatric Medicine, University of Glasgow, Glasgow, UK
| | | | - Camilla Young
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | - David J Stott
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow , UK
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Burton JK, Stott DJ, McShane R, Noel-Storr AH, Swann-Price RS, Quinn TJ. Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) for the early detection of dementia across a variety of healthcare settings. Cochrane Database Syst Rev 2021; 7:CD011333. [PMID: 34275145 PMCID: PMC8406787 DOI: 10.1002/14651858.cd011333.pub3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) is a structured interview based on informant responses that is used to assess for possible dementia. IQCODE has been used for retrospective or contemporaneous assessment of cognitive decline. There is considerable interest in tests that may identify those at future risk of developing dementia. Assessing a population free of dementia for the prospective development of dementia is an approach often used in studies of dementia biomarkers. In theory, questionnaire-based assessments, such as IQCODE, could be used in a similar way, assessing for dementia that is diagnosed on a later (delayed) assessment. OBJECTIVES To determine the accuracy of the informant-based questionnaire IQCODE for the early detection of dementia across a variety of health care settings. SEARCH METHODS We searched these sources on 16 January 2016: ALOIS (Cochrane Dementia and Cognitive Improvement Group), MEDLINE Ovid SP, Embase Ovid SP, PsycINFO Ovid SP, BIOSIS Previews on Thomson Reuters Web of Science, Web of Science Core Collection (includes Conference Proceedings Citation Index) on Thomson Reuters Web of Science, CINAHL EBSCOhost, and LILACS BIREME. We also searched sources specific to diagnostic test accuracy: MEDION (Universities of Maastricht and Leuven); DARE (Database of Abstracts of Reviews of Effects, in the Cochrane Library); HTA Database (Health Technology Assessment Database, in the Cochrane Library), and ARIF (Birmingham University). We checked reference lists of included studies and reviews, used searches of included studies in PubMed to track related articles, and contacted research groups conducting work on IQCODE for dementia diagnosis to try to find additional studies. We developed a sensitive search strategy; search terms were designed to cover key concepts using several different approaches run in parallel, and included terms relating to cognitive tests, cognitive screening, and dementia. We used standardised database subject headings, such as MeSH terms (in MEDLINE) and other standardised headings (controlled vocabulary) in other databases, as appropriate. SELECTION CRITERIA We selected studies that included a population free from dementia at baseline, who were assessed with the IQCODE and subsequently assessed for the development of dementia over time. The implication was that at the time of testing, the individual had a cognitive problem sufficient to result in an abnormal IQCODE score (defined by the study authors), but not yet meeting dementia diagnostic criteria. DATA COLLECTION AND ANALYSIS We screened all titles generated by the electronic database searches, and reviewed abstracts of all potentially relevant studies. Two assessors independently checked the full papers for eligibility and extracted data. We determined quality assessment (risk of bias and applicability) using the QUADAS-2 tool, and reported quality using the STARDdem tool. MAIN RESULTS From 85 papers describing IQCODE, we included three papers, representing data from 626 individuals. Of this total, 22% (N = 135/626) were excluded because of prevalent dementia. There was substantial attrition; 47% (N = 295) of the study population received reference standard assessment at first follow-up (three to six months) and 28% (N = 174) received reference standard assessment at final follow-up (one to three years). Prevalence of dementia ranged from 12% to 26% at first follow-up and 16% to 35% at final follow-up. The three studies were considered to be too heterogenous to combine, so we did not perform meta-analyses to describe summary estimates of interest. Included patients were poststroke (two papers) and hip fracture (one paper). The IQCODE was used at three thresholds of positivity (higher than 3.0, higher than 3.12 and higher than 3.3) to predict those at risk of a future diagnosis of dementia. Using a cut-off of 3.0, IQCODE had a sensitivity of 0.75 (95%CI 0.51 to 0.91) and a specificity of 0.46 (95%CI 0.34 to 0.59) at one year following stroke. Using a cut-off of 3.12, the IQCODE had a sensitivity of 0.80 (95%CI 0.44 to 0.97) and specificity of 0.53 (95C%CI 0.41 to 0.65) for the clinical diagnosis of dementia at six months after hip fracture. Using a cut-off of 3.3, the IQCODE had a sensitivity of 0.84 (95%CI 0.68 to 0.94) and a specificity of 0.87 (95%CI 0.76 to 0.94) for the clinical diagnosis of dementia at one year after stroke. In generaI, the IQCODE was sensitive for identification of those who would develop dementia, but lacked specificity. Methods for both excluding prevalent dementia at baseline and assessing for the development of dementia were varied, and had the potential to introduce bias. AUTHORS' CONCLUSIONS Included studies were heterogenous, recruited from specialist settings, and had potential biases. The studies identified did not allow us to make specific recommendations on the use of the IQCODE for the future detection of dementia in clinical practice. The included studies highlighted the challenges of delayed verification dementia research, with issues around prevalent dementia assessment, loss to follow-up over time, and test non-completion potentially limiting the studies. Future research should recognise these issues and have explicit protocols for dealing with them.
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Affiliation(s)
- Jennifer K Burton
- Academic Geriatric Medicine, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - David J Stott
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow , UK
| | | | | | | | - Terry J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Potter CM, Peters M, Cundell M, McShane R, Fitzpatrick R. Use of the Long-Term Conditions Questionnaire (LTCQ) for monitoring health-related quality of life in people affected by cognitive impairment including dementia: pilot study in UK memory clinic services. Qual Life Res 2021; 30:1641-1652. [PMID: 33575918 PMCID: PMC8178132 DOI: 10.1007/s11136-021-02762-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE The aim of this study was to validate the Long-Term Conditions Questionnaire (LTCQ) among patients using memory clinic services in England. LTCQ is a short self-administered measure of 'living well with long-term conditions' that has not been previously tested in patients with cognitive impairment. METHODS The mixed-methods study included cognitive interviews to test the comprehensibility and content validity of LTCQ from the patient's perspective, followed by a pilot survey to test the measure's internal consistency, construct validity, structural validity, and responsiveness. Participants were recruited through memory clinics following a diagnosis of mild cognitive impairment or dementia. RESULTS Interview respondents (n = 12) all found LTCQ's content relevant, with only minor formatting modifications required. Among survey respondents (n = 105), most patients (86%) were able to self-report answers to LTCQ. High multimorbidity among the sample was associated with reduced LTCQ and EQ-5D scores. Internal consistency of LTCQ was high (Cronbach's α = 0.93), no floor or ceiling effects were observed, and missing data levels were low. Factor analysis results further supported LTCQ's structural validity, and predicted positive correlation with EQ-5D indicated construct validity. Score changes observed in a four-month follow-up survey (n = 61) are suggestive of LTCQ's responsiveness. CONCLUSION LTCQ is a valid means of assessing health-related quality of life for people living with cognitive impairment (including dementia) in the early period of support following diagnosis. Owing to high levels of multimorbidity in this patient population, LTCQ offers an advantage over dementia-specific measures in capturing the cumulative impact of all LTCs experienced by the patient.
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Affiliation(s)
- Caroline M Potter
- Nuffield Department of Population Health, Health Services Research Unit, University of Oxford, Oxford, UK.
- Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Oxford, Oxford Health NHS Foundation Trust, Oxford, UK.
| | - Michele Peters
- Nuffield Department of Population Health, Health Services Research Unit, University of Oxford, Oxford, UK
| | | | | | - Ray Fitzpatrick
- Nuffield Department of Population Health, Health Services Research Unit, University of Oxford, Oxford, UK
- Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Oxford, Oxford Health NHS Foundation Trust, Oxford, UK
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Lascelles K, Marzano L, Brand F, Trueman H, McShane R, Hawton K. Ketamine treatment for individuals with treatment-resistant depression: longitudinal qualitative interview study of patient experiences. BJPsych Open 2020; 7:e9. [PMID: 33283696 PMCID: PMC7791565 DOI: 10.1192/bjo.2020.132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Ketamine has recently received considerable attention regarding its antidepressant and anti-suicidal effects. Trials have generally focused on short-term effects of single intravenous infusions. Research on patient experiences is lacking. AIMS To investigate the experiences over time of individuals receiving ketamine treatment in a routine clinic, including impacts on mood and suicidality. METHOD Twelve fee-paying patients with treatment-resistant depression (6 females, 6 males, age 21-70 years; 11 reporting suicidality and 6 reporting self-harm) who were assessed as eligible for ketamine treatment participated in up to three semi-structured interviews: before treatment started, a few weeks into treatment and ≥2 months later. Data were analysed thematically. RESULTS Most participants hoped that ketamine would provide respite from their depression. Nearly all experienced improvement in mood following initial treatments, ranging from negligible to dramatic, and eight reported a reduction in suicidality. Improvements were transitory for most participants, although two experienced sustained consistent benefit and two had sustained but limited improvement. Some participants described hopelessness when treatment stopped working, paralleled by increased suicidal ideation for three participants. The transient nature and cost of treatment were problematic. Eleven participants experienced side-effects, which were significant for two participants. Suggestions for improving treatment included closer monitoring and adjunctive psychological therapy. CONCLUSIONS Ketamine treatment was generally experienced as effective in improving mood and reducing suicidal ideation in the short term, but the lack of longer-term benefit was challenging for participants, as was treatment cost. Informed consent procedures should refer to the possibilities of relapse and associated increased hopelessness and suicidality.
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Affiliation(s)
- Karen Lascelles
- Oxford Health NHS Foundation Trust; and Centre for Suicide Research, Department of Psychiatry, University of Oxford, UK
| | - Lisa Marzano
- Faculty of Science and Technology, Middlesex University, UK
| | - Fiona Brand
- Oxford Health NHS Foundation Trust; and Centre for Suicide Research, Department of Psychiatry, University of Oxford, UK
| | | | - Rupert McShane
- Department of Psychiatry, University of Oxford; and Oxford Health NHS Foundation Trust, UK
| | - Keith Hawton
- Centre for Suicide Research, Department of Psychiatry, University of Oxford; and Oxford Health NHS Foundation Trust, UK
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Howard R, Zubko O, Bradley R, Harper E, Pank L, O'Brien J, Fox C, Tabet N, Livingston G, Bentham P, McShane R, Burns A, Ritchie C, Reeves S, Lovestone S, Ballard C, Noble W, Nilforooshan R, Wilcock G, Gray R. Minocycline at 2 Different Dosages vs Placebo for Patients With Mild Alzheimer Disease: A Randomized Clinical Trial. JAMA Neurol 2020; 77:164-174. [PMID: 31738372 PMCID: PMC6865324 DOI: 10.1001/jamaneurol.2019.3762] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Question Can 2 years of minocycline treatment modify the course of mild Alzheimer disease? Findings In this randomized clinical trial that included 544 participants, 24 months of minocycline treatment did not significantly delay progression of functional and cognitive impairment compared with placebo. Meaning Minocycline is not a candidate for disease modification for patients with symptomatic Alzheimer disease. Importance There are no disease-modifying treatments for Alzheimer disease (AD), the most common cause of dementia. Minocycline is anti-inflammatory, protects against the toxic effects of β-amyloid in vitro and in animal models of AD, and is a credible repurposed treatment candidate. Objective To determine whether 24 months of minocycline treatment can modify cognitive and functional decline in patients with mild AD. Design, Setting, and Participants Participants were recruited into a double-blind randomized clinical trial from May 23, 2014, to April 14, 2016, with 24 months of treatment and follow-up. This multicenter study in England and Scotland involved 32 National Health Service memory clinics within secondary specialist services for people with dementia. From 886 screened patients, 554 patients with a diagnosis of mild AD (Standardised Mini-Mental State Examination [sMMSE] score ≥24) were randomized. Interventions Participants were randomly allocated 1:1:1 in a semifactorial design to receive minocycline (400 mg/d or 200 mg/d) or placebo for 24 months. Main Outcomes and Measures Primary outcome measures were decrease in sMMSE score and Bristol Activities of Daily Living Scale (BADLS), analyzed by intention-to-treat repeated-measures regression. Results Of 544 eligible participants (241 women and 303 men), the mean (SD) age was 74.3 (8.2) years, and the mean (SD) sMMSE score was 26.4 (1.9). Fewer participants completed 400-mg minocycline hydrochloride treatment (28.8% [53 of 184]) than 200-mg minocycline treatment (61.9% [112 of 181]) or placebo (63.7% [114 of 179]; P < .001), mainly because of gastrointestinal symptoms (42 in the 400-mg group, 15 in the 200-mg group, and 10 in the placebo group; P < .001), dermatologic adverse effects (10 in the 400-mg group, 5 in the 200-mg group, and 1 in the placebo group; P = .02), and dizziness (14 in the 400-mg group, 3 in the 200-mg group, and 1 in the placebo group; P = .01). Assessment rates were lower in the 400-mg group: 68.4% (119 of 174 expected) for sMMSE at 24 months compared with 81.8% (144 of 176) for the 200-mg group and 83.8% (140 of 167) for the placebo group. Decrease in sMMSE scores over 24 months in the combined minocycline group was similar to that in the placebo group (4.1 vs 4.3 points). The combined minocycline group had mean sMMSE scores 0.1 points higher than the placebo group (95% CI, −1.1 to 1.2; P = .90). The decrease in mean sMMSE scores was less in the 400-mg group than in the 200-mg group (3.3 vs 4.7 points; treatment effect = 1.2; 95% CI, −0.1 to 2.5; P = .08). Worsening of BADLS scores over 24 months was similar in all groups: 5.7 in the 400-mg group, 6.6 in the 200-mg group, and 6.2 in the placebo groups (treatment effect for minocycline vs placebo = –0.53; 95% CI, −2.4 to 1.3; P = .57; treatment effect for 400 mg vs 200 mg of minocycline = –0.31; 95% CI, −0.2 to 1.8; P = .77). Results were similar in different patient subgroups and in sensitivity analyses adjusting for missing data. Conclusions and Relevance Minocycline did not delay the progress of cognitive or functional impairment in people with mild AD during a 2-year period. This study also found that 400 mg of minocycline is poorly tolerated in this population. Trial Registration isrctn.org Identifier: ISRCTN16105064
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Affiliation(s)
- Robert Howard
- Division of Psychiatry, University College London, London, United Kingdom
| | - Olga Zubko
- Old Age Psychiatry, King's College London, London, United Kingdom
| | - Rosie Bradley
- Medical Research Council Population Health Research Unit, University of Oxford, Oxford, United Kingdom
| | - Emma Harper
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Lynn Pank
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - John O'Brien
- Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
| | - Chris Fox
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Naji Tabet
- Department of Old Age Psychiatry, University of Sussex, Brighton, United Kingdom
| | - Gill Livingston
- Division of Psychiatry, University College London, London, United Kingdom
| | - Peter Bentham
- Birmingham and Solihull Mental Health National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Rupert McShane
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - Alistair Burns
- Department of Old Age Psychiatry, University of Manchester, Manchester, United Kingdom
| | - Craig Ritchie
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Suzanne Reeves
- Division of Psychiatry, University College London, London, United Kingdom
| | - Simon Lovestone
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - Clive Ballard
- Medical School, University of Exeter, Exeter, United Kingdom
| | - Wendy Noble
- Department of Basic and Clinical Neuroscience, King's College London, London, United Kingdom
| | - Ramin Nilforooshan
- Surrey and Borders Partnership National Health Service Foundation Trust, United Kingdom
| | - Gordon Wilcock
- Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Richard Gray
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
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Abstract
BACKGROUND In the UK, medical cannabis was approved in November 2018, leading many patients to believe that the medicine would now be available on the NHS. Yet, to date, there have been only 12 NHS prescriptions and less than 60 prescriptions in total. In marked contrast, a recent patient survey by the Centre for Medical Cannabis (Couch, 2020) found 1.4 m people are using illicit cannabis for medical problems. AIMS Such a mismatch between demand and supply is rare in medicine. This article outlines some of the current controversies about medical cannabis that underpin this disparity, beginning by contrasting current medical evidence from research studies with patient-reported outcomes. OUTCOMES Although definite scientific evidence is scarce for most conditions, there is significant patient demand for access to medical cannabis. This disparity poses a challenge for prescribers, and there are many concerns of physicians when deciding if, and how, to prescribe medical cannabis which still need to be addressed. Potential solutions are outlined as to how the medical profession and regulators could respond to the strong demand from patients and families for access to medical cannabis to treat chronic illnesses when there is often a limited scientific evidence base on whether and how to use it in many of these conditions. CONCLUSIONS There is a need to maximise both clinical research and patient benefit, in a safe, cautious and ethical manner, so that those patients for whom cannabis is shown to be effective can access it. We hope our discussion and outlines for future progress offer a contribution to this process.
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Affiliation(s)
| | - David S Baldwin
- Clinical and Experimental Sciences, University of Southampton, Southampton, UK
- University of Cape Town, Cape Town, South Africa
| | | | - Steve Bazire
- School of Pharmacy, University of East Anglia, Norwich, UK
| | | | - H Valerie Curran
- Clinical, Education and Health Psychology, University College London, London, UK
| | - Rupert McShane
- Interventional Psychiatry Service, Oxford Health NHS Foundation Trust, Oxford, UK
| | - Lawrence D Phillips
- Department of Management, London School of Economics & Political Science, London, UK
| | - Ilina Singh
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - David J Nutt
- Department of Brain Sciences, Imperial College London, London, UK
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18
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Tsiachristas A, Potter CM, Rocks S, Peters M, Cundell M, McShane R, Batchelder L, Fox D, Forder JE, Jones K, Waite F, Freeman D, Fitzpatrick R. Estimating EQ-5D utilities based on the Short-Form Long Term Conditions Questionnaire (LTCQ-8). Health Qual Life Outcomes 2020; 18:279. [PMID: 32795317 PMCID: PMC7427949 DOI: 10.1186/s12955-020-01506-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 07/22/2020] [Indexed: 11/29/2022] Open
Abstract
Purpose The aim of this work was to develop a mapping algorithm for estimating EuroQoL 5 Dimension (EQ-5D) utilities from responses to the Long-Term Conditions Questionnaire (LTCQ), thus increasing LTCQ’s potential as a comprehensive outcome measure for evaluating integrated care initiatives. Methods We combined data from three studies to give a total sample of 1334 responses. In each of the three datasets, we randomly selected 75% of the sample and combined the selected random samples to generate the estimation dataset, which consisted of 1001 patients. The unselected 25% observations from each dataset were combined to generate an internal validation dataset of 333 patients. We used direct mapping models by regressing responses to the LTCQ-8 directly onto EQ-5D-5L and EQ-5D-3L utilities as well as response (or indirect) mapping to predict the response level that patients selected for each of the five EQ-5D-5L domains. Several models were proposed and compared on mean squared error and mean absolute error. Results A two-part model with OLS was the best performing based on the mean squared error (0.038) and mean absolute error (0.147) when estimating the EQ-5D-5L utilities. A multinomial response mapping model using LTCQ-8 responses was used to predict EQ-5D-5L responses levels. Conclusions This study provides a mapping algorithm for estimating EQ-5D utilities from LTCQ responses. The results from this study can help broaden the applicability of the LTCQ by producing utility values for use in economic analyses.
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Affiliation(s)
- Apostolos Tsiachristas
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford, OX3 7LF, UK.
| | - Caroline M Potter
- Health Services Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Stephen Rocks
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford, OX3 7LF, UK
| | - Michele Peters
- Health Services Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | | | - Laurie Batchelder
- Personal Social Services Research Unit, School of Social Policy Sociology and Social Research, University of Kent, Canterbury, UK
| | - Diane Fox
- Personal Social Services Research Unit, School of Social Policy Sociology and Social Research, University of Kent, Canterbury, UK
| | - Julien E Forder
- Personal Social Services Research Unit, School of Social Policy Sociology and Social Research, University of Kent, Canterbury, UK
| | - Karen Jones
- Personal Social Services Research Unit, School of Social Policy Sociology and Social Research, University of Kent, Canterbury, UK
| | - Felicity Waite
- Oxford Health NHS Foundation Trust, Oxford, UK.,Department of Psychiatry, University of Oxford, Oxford, UK
| | - Daniel Freeman
- Oxford Health NHS Foundation Trust, Oxford, UK.,Department of Psychiatry, University of Oxford, Oxford, UK
| | - Ray Fitzpatrick
- Health Services Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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19
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Short B, Dong V, Gálvez V, Vulovic V, Martin D, Bayes AJ, Zarate CA, Murrough JW, McLoughlin DM, Riva-Posse P, Schoevers R, Fraguas R, Glue P, Fam J, McShane R, Loo CK. Development of the Ketamine Side Effect Tool (KSET). J Affect Disord 2020; 266:615-620. [PMID: 32056935 PMCID: PMC7693479 DOI: 10.1016/j.jad.2020.01.120] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 12/20/2019] [Accepted: 01/20/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Currently, no specific, systematic assessment tool for the monitoring and reporting of ketamine-related side effects exists. Our aim was to develop a comprehensive Ketamine Side Effect Tool (KSET) to capture acute and longer-term side effects associated with repeated ketamine treatments. METHODS Informed by systematic review data and clinical research, we drafted a list of the most commonly reported side effects. Face and content validation were obtained via feedback from collaborators with expertise in psychiatry and anaesthetics, clinical trial piloting and a modified Delphi Technique involving ten international experts. RESULTS The final version consisted of four forms that collect information at time points: screening, baseline, immediately after a single treatment, and longer-term follow-up. Instructions were developed to guide users and promote consistent utilisation. LIMITATIONS Further evaluation of feasibility, construct validity and reliability is required, and is planned across multiple international sites. CONCLUSIONS The structured Ketamine Side Effect Tool (KSET) was developed, with confirmation of content and face validity via a Delphi consensus process. This tool is timely, given the paucity of data regarding ketamine's safety, tolerability and abuse potential over the longer term, and its recent adoption internationally as a clinical treatment for depression. Although based on data from depression studies, the KSET has potential applicability for ketamine (or derivatives) used in other medical disorders, including chronic pain. We recommend its utilisation for both research and clinical scenarios, including data registries.
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Affiliation(s)
- Brooke Short
- School of Medicine and Public Health, The University of Newcastle, Newcastle, Australia,Gosford Hospital Gosford, Australia
| | - Vanessa Dong
- School of Psychiatry, University of New South Wales and Black Dog Institute, Sydney, Australia
| | - Verònica Gálvez
- Corporacio Sanitaria Parc Tauli, Universitat Autonoma de Barcelona, I3PT, Institut d’Investigacio i Innovacio Parc Tauli Sabadell Barcelona, Spain
| | | | - Donel Martin
- School of Psychiatry, University of New South Wales and Black Dog Institute, Sydney, Australia
| | - Adam J Bayes
- School of Psychiatry, University of New South Wales, Sydney, Australia,Black Dog Institute, Sydney, Australia
| | - Carlos A Zarate
- Division of Intramural Research Program, National Institute of Mental Health, MD, United States
| | - James W Murrough
- Depression and Anxiety Centre for Discovery and Treatment, Icahn School of Medicine at Mount Sinai New York, NY, United States
| | - Declan M McLoughlin
- Department of Psychiatry, Trinity College Institute of Neuroscience, Trinity College, Dublin, Ireland
| | - Patricio Riva-Posse
- Department of Psychiatry and Behavioral Sciences at Emory University, Atlanta, GA, United States
| | - Robert Schoevers
- The University Medical Center Groningen (UMCG), Groningen, the Netherlands
| | - Renerio Fraguas
- Department and Institute of Psychiatry, University of Sao Paulo (USP), School of Medicine, Division of Psychiatry and Psychology, University Hospital (HU), USP Laboratório de Investigação Médica, Recife, Brazil
| | - Paul Glue
- Southern DHB and Hazel Buckland Chair in Psychological Medicine, University of Otago, Dunedin, New Zealand
| | - Johnson Fam
- Department of Psychological Medicine, National University Hospital,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Rupert McShane
- Department of Psychiatry, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | - Colleen K Loo
- School of Psychiatry, University of New South Wales, Sydney, Australia; St George Hospital, Sydney, Australia; Black Dog Institute, Sydney, Australia; Wesley Hospital, Sydney, Australia.
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20
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Ochs-Ross R, Daly EJ, Zhang Y, Lane R, Lim P, Morrison RL, Hough D, Manji H, Drevets WC, Sanacora G, Steffens DC, Adler C, McShane R, Gaillard R, Wilkinson ST, Singh JB. Efficacy and Safety of Esketamine Nasal Spray Plus an Oral Antidepressant in Elderly Patients With Treatment-Resistant Depression-TRANSFORM-3. Am J Geriatr Psychiatry 2020; 28:121-141. [PMID: 31734084 DOI: 10.1016/j.jagp.2019.10.008] [Citation(s) in RCA: 150] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 10/11/2019] [Accepted: 10/14/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Elderly patients with major depression have a poorer prognosis, are less responsive to treatment, and show greater functional decline compared with younger patients, highlighting the need for effective treatment. METHODS This phase 3 double-blind study randomized patients with treatment-resistant depression (TRD) ≥65 years (1:1) to flexibly dosed esketamine nasal spray and new oral antidepressant (esketamine/antidepressant) or new oral antidepressant and placebo nasal spray (antidepressant/placebo). The primary endpoint was change in the Montgomery-Åsberg Depression Rating Scale (MADRS) from baseline to day 28. Analyses included a preplanned analysis by age (65-74 versus ≥75 years) and post-hoc analyses including age at depression onset. RESULTS For the primary endpoint, the median-unbiased estimate of the treatment difference (95% CI) was -3.6 (-7.20, 0.07); weighted combination test using MMRM analyses z = 1.89, two-sided p = 0.059. Adjusted mean (95% CI) difference for change in MADRS score between treatment groups was -4.9 (-8.96, -0.89; t = -2.4, df = 127; two-sided nominal p = 0.017) for patients 65 to 74 years versus -0.4 (-10.38, 9.50; t = -0.09, two-sided nominal p = 0.930) for those ≥75 years, and -6.1 (-10.33, -1.81; t = -2.8, df = 127; two-sided nominal p = 0.006) for patients with depression onset <55 years and 3.1 (-4.51, 10.80; t = 0.8, two-sided nominal p = 0.407) for those ≥55 years. Patients who rolled over into the long-term open-label study showed continued improvement with esketamine following 4 additional treatment weeks. CONCLUSIONS Esketamine/antidepressant did not achieve statistical significance for the primary endpoint. Greater differences between treatment arms were seen for younger patients (65-74 years) and patients with earlier onset of depression (<55 years).
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Affiliation(s)
- Rachel Ochs-Ross
- Janssen Research & Development, LLC (RO-R, EJD, RL, PL, RLM, DH, HM), Titusville, NJ.
| | - Ella J Daly
- Janssen Research & Development, LLC (RO-R, EJD, RL, PL, RLM, DH, HM), Titusville, NJ
| | - Yun Zhang
- Janssen Research & Development, LLC (YZ), Fremont, CA
| | - Rosanne Lane
- Janssen Research & Development, LLC (RO-R, EJD, RL, PL, RLM, DH, HM), Titusville, NJ
| | - Pilar Lim
- Janssen Research & Development, LLC (RO-R, EJD, RL, PL, RLM, DH, HM), Titusville, NJ
| | - Randall L Morrison
- Janssen Research & Development, LLC (RO-R, EJD, RL, PL, RLM, DH, HM), Titusville, NJ
| | - David Hough
- Janssen Research & Development, LLC (RO-R, EJD, RL, PL, RLM, DH, HM), Titusville, NJ
| | - Husseini Manji
- Janssen Research & Development, LLC (RO-R, EJD, RL, PL, RLM, DH, HM), Titusville, NJ
| | - Wayne C Drevets
- Janssen Research & Development, LLC (WCD, JBS), San Diego, CA
| | | | - David C Steffens
- University of Connecticut School of Medicine (DCS), Farmington, CT
| | - Caleb Adler
- University of Cincinnati College of Medicine (CA), Cincinnati, OH
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21
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McShane R, Baldwin DS, McAllister-Williams RH, Stone JM, Taylor D, Winstock AR, Young AH. Esketamine and the Need for a New Type of Registry for Drugs With Abuse Potential. Am J Psychiatry 2019; 176:966. [PMID: 31672039 DOI: 10.1176/appi.ajp.2019.19060631] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Rupert McShane
- Department of Psychiatry, University of Oxford, and Oxford Health NHS Foundation Trust, Oxford, U.K. (McShane); Department of Psychiatry and Pharmacology, University of Southampton, Southampton, U.K. (Baldwin); Department of Neurodegenerative, Cerebrovascular, and Psychiatric Disorders, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, U.K. (McAllister-Williams); Maudsley Hospital (Taylor), Department of Neuroimaging (Stone), and Department of Psychological Medicine (Young), Institute of Psychiatry, Psychology, and Neuroscience, King's College London and South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, London; Department of Behavioral Science and Health, Institute of Epidemiology and Health Care, University College London, London (Winstock)
| | - David S Baldwin
- Department of Psychiatry, University of Oxford, and Oxford Health NHS Foundation Trust, Oxford, U.K. (McShane); Department of Psychiatry and Pharmacology, University of Southampton, Southampton, U.K. (Baldwin); Department of Neurodegenerative, Cerebrovascular, and Psychiatric Disorders, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, U.K. (McAllister-Williams); Maudsley Hospital (Taylor), Department of Neuroimaging (Stone), and Department of Psychological Medicine (Young), Institute of Psychiatry, Psychology, and Neuroscience, King's College London and South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, London; Department of Behavioral Science and Health, Institute of Epidemiology and Health Care, University College London, London (Winstock)
| | - R Hamish McAllister-Williams
- Department of Psychiatry, University of Oxford, and Oxford Health NHS Foundation Trust, Oxford, U.K. (McShane); Department of Psychiatry and Pharmacology, University of Southampton, Southampton, U.K. (Baldwin); Department of Neurodegenerative, Cerebrovascular, and Psychiatric Disorders, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, U.K. (McAllister-Williams); Maudsley Hospital (Taylor), Department of Neuroimaging (Stone), and Department of Psychological Medicine (Young), Institute of Psychiatry, Psychology, and Neuroscience, King's College London and South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, London; Department of Behavioral Science and Health, Institute of Epidemiology and Health Care, University College London, London (Winstock)
| | - James M Stone
- Department of Psychiatry, University of Oxford, and Oxford Health NHS Foundation Trust, Oxford, U.K. (McShane); Department of Psychiatry and Pharmacology, University of Southampton, Southampton, U.K. (Baldwin); Department of Neurodegenerative, Cerebrovascular, and Psychiatric Disorders, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, U.K. (McAllister-Williams); Maudsley Hospital (Taylor), Department of Neuroimaging (Stone), and Department of Psychological Medicine (Young), Institute of Psychiatry, Psychology, and Neuroscience, King's College London and South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, London; Department of Behavioral Science and Health, Institute of Epidemiology and Health Care, University College London, London (Winstock)
| | - David Taylor
- Department of Psychiatry, University of Oxford, and Oxford Health NHS Foundation Trust, Oxford, U.K. (McShane); Department of Psychiatry and Pharmacology, University of Southampton, Southampton, U.K. (Baldwin); Department of Neurodegenerative, Cerebrovascular, and Psychiatric Disorders, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, U.K. (McAllister-Williams); Maudsley Hospital (Taylor), Department of Neuroimaging (Stone), and Department of Psychological Medicine (Young), Institute of Psychiatry, Psychology, and Neuroscience, King's College London and South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, London; Department of Behavioral Science and Health, Institute of Epidemiology and Health Care, University College London, London (Winstock)
| | - Adam R Winstock
- Department of Psychiatry, University of Oxford, and Oxford Health NHS Foundation Trust, Oxford, U.K. (McShane); Department of Psychiatry and Pharmacology, University of Southampton, Southampton, U.K. (Baldwin); Department of Neurodegenerative, Cerebrovascular, and Psychiatric Disorders, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, U.K. (McAllister-Williams); Maudsley Hospital (Taylor), Department of Neuroimaging (Stone), and Department of Psychological Medicine (Young), Institute of Psychiatry, Psychology, and Neuroscience, King's College London and South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, London; Department of Behavioral Science and Health, Institute of Epidemiology and Health Care, University College London, London (Winstock)
| | - Allan H Young
- Department of Psychiatry, University of Oxford, and Oxford Health NHS Foundation Trust, Oxford, U.K. (McShane); Department of Psychiatry and Pharmacology, University of Southampton, Southampton, U.K. (Baldwin); Department of Neurodegenerative, Cerebrovascular, and Psychiatric Disorders, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, U.K. (McAllister-Williams); Maudsley Hospital (Taylor), Department of Neuroimaging (Stone), and Department of Psychological Medicine (Young), Institute of Psychiatry, Psychology, and Neuroscience, King's College London and South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, London; Department of Behavioral Science and Health, Institute of Epidemiology and Health Care, University College London, London (Winstock)
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22
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Forsyth K, Henderson C, Davis L, Singh Roy A, Dunk B, Curnow E, Gathercole R, Lam N, Harper E, Leroi I, Woolham J, Fox C, O'Brien J, Bateman A, Poland F, Bentham P, Burns A, Davies A, Gray R, Bradley R, Knapp M, Newman S, McShane R, Ritchie C, Talbot E, Hooper E, Winson R, Scutt B, Ordonez V, Nunn S, Lavelle G, Howard R. Assessment of need and practice for assistive technology and telecare for people with dementia-The ATTILA (Assistive Technology and Telecare to maintain Independent Living At home for people with dementia) trial. Alzheimers Dement (N Y) 2019; 5:420-430. [PMID: 31517029 PMCID: PMC6728826 DOI: 10.1016/j.trci.2019.07.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Introduction The objective of this study was to define current assistive technology and telecare (ATT) practice for people with dementia living at home. Methods This is a randomized controlled trial (N = 495) of ATT assessment and ATT installation intervention, compared with control (restricted ATT package). ATT assessment and installation data were collected. Qualitative work identified value networks delivering ATT, established an ATT assessment standard. Results ATT was delivered by public and not-for-profit telecare networks. ATT assessments showed 52% fidelity to the ATT assessment standard. Areas of assessment most frequently leading to identifying ATT need were daily activities (93%), memory (89%), and problem-solving (83%). ATT needs and recommendations were weakly correlated (τ = 0.242; P < .000), with ATT recommendations and installations moderately correlated (τ = −0.470; P < .000). Half (53%) of recommended technology was not installed. Safety concerns motivated 38% of installations. Discussion Assessment recommendations were routinely disregarded at the point of installation. ATT was commonly recommended for safety and seldom for supporting leisure.
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Affiliation(s)
- Kirsty Forsyth
- School of Health Sciences, Queen Margaret University, Edinburgh, UK
| | - Catherine Henderson
- Personal Social Services Research Unit, London School of Economics and Political Science, London, UK
| | | | - Anusua Singh Roy
- School of Health Sciences, Queen Margaret University, Edinburgh, UK
| | - Barbara Dunk
- South London and Maudsley NHS Foundation Trust, The Maudsley, UK
| | - Eleanor Curnow
- School of Health Sciences, Queen Margaret University, Edinburgh, UK
| | | | | | | | - Iracema Leroi
- School of Community Based Medicine, University of Manchester, Manchester, UK
| | - John Woolham
- Social Care Workforce Research Unit, King's College London, London, UK
| | - Chris Fox
- School of Medicine, Health Policy and Practice, University of East Anglia, Norwich, Norfolk, UK
| | - John O'Brien
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Andrew Bateman
- Oliver Zangwill Centre for Neuropsychological Rehabilitation, Princess of Wales Hospital, Ely, UK
| | - Fiona Poland
- School of Allied Health Professionals, University of East Anglia, Norwich, Norfolk, UK
| | | | - Alistair Burns
- School of Community Based Medicine, University of Manchester, Manchester, UK
| | - Anna Davies
- School of Community and Health Science, City University, London, UK
| | | | | | - Martin Knapp
- Department of Old Age Psychiatry, Institute of Psychiatry, London, UK
| | - Stanton Newman
- School of Community and Health Science, City University, London, UK
| | - Rupert McShane
- Oxford Health NHS Foundation Trust, Warneford Hospital, Headington, Oxford, UK
| | - Craig Ritchie
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Emma Talbot
- Norfolk and Suffolk NHS Foundation Trust, Suffolk, UK
| | | | - Rachel Winson
- Cambridgeshire Community Services NHS Trust, Oliver Zangwill Centre, Ely, UK
| | - Bethany Scutt
- Department of Old Age Psychiatry, Institute of Psychiatry, London, UK
| | - Victoria Ordonez
- Cambridgeshire Community Services NHS Trust, Oliver Zangwill Centre, Ely, UK
| | - Samantha Nunn
- Cambridgeshire Community Services NHS Trust, Oliver Zangwill Centre, Ely, UK
| | - Grace Lavelle
- Department of Old Age Psychiatry, Institute of Psychiatry, London, UK
| | - Robert Howard
- Division of Psychiatry, University College London, London, UK
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Lascelles K, Marzano L, Brand F, Trueman H, McShane R, Hawton K. Effects of ketamine treatment on suicidal ideation: a qualitative study of patients' accounts following treatment for depression in a UK ketamine clinic. BMJ Open 2019; 9:e029108. [PMID: 31420388 PMCID: PMC6701814 DOI: 10.1136/bmjopen-2019-029108] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE It is recognised that ketamine treatment can reduce suicidal ideation (SI) in people with depression, at least in the short term. However, information is lacking on patients' perspectives on such effects. Studying these can contribute to greater understanding of the mechanisms underlying impact of ketamine treatment on SI. The aim of this study was to investigate patients' reports of the impact of treatment on their SI, the duration of effects and possible mechanisms. DESIGN AND SETTING This qualitative study consisted of semi-structured interviews with patients who had received ketamine treatment for depression. Interview data were analysed thematically. PARTICIPANTS Fourteen patients (8 females, 6 males, aged 24-64 years) who had received treatment with ketamine for treatment-resistant depression, and had SI at the initiation of treatment. Two participants also had a diagnosis of bipolar type 1 and two of emotionally unstable personality disorder. Eight had a history of self-harm. RESULTS SI reduced following ketamine treatment in 12 out of 14 participants for periods of a few hours following a single treatment to up to three years with ongoing treatment. Reduction of SI was variable in terms of extent and duration, and re-emergence of suicidal thoughts often occurred when treatment ceased. Participants' accounts indicated that reduced SI was associated with improved mood and reduced anxiety, as were clarity of thought, focus and concentration, and ability to function. Participants reported experiencing some or all of these effects in various orders of occurrence. CONCLUSION Generally, ketamine treatment was experienced as effective in reducing SI, although duration of effects varied considerably. Patients' perspectives indicated similarities in the mechanisms of reduction in SI, but some differences in their manifestation, particularly in relation to chronology. Experiences of this cohort suggest that reduced anxiety and improvement in ability to think and function were important mechanisms alongside, or in some cases independently of, improvement in mood. Further studies of patients' experiences are required to gain enhanced understanding of the variability of effects of ketamine on SI and functionality.
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Affiliation(s)
- Karen Lascelles
- Oxford Health NHS Foundation Trust, Oxford, UK
- Department of Psychiatry, Centre for Suicide Research, University of Oxford, Oxford, UK
| | - Lisa Marzano
- Department of Psychology, Middlesex University, London, UK
| | - Fiona Brand
- Oxford Health NHS Foundation Trust, Oxford, UK
- Department of Psychiatry, Centre for Suicide Research, University of Oxford, Oxford, UK
| | | | - Rupert McShane
- Oxford Health NHS Foundation Trust, Oxford, UK
- Cochrane Dementia and Cognitive Improvement Group (CDCIG), Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Keith Hawton
- Oxford Health NHS Foundation Trust, Oxford, UK
- Department of Psychiatry, Centre for Suicide Research, University of Oxford, Oxford, UK
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Jilka S, Murray C, Wieczorek A, Griffiths H, Wykes T, McShane R. Exploring patients' and carers' views about the clinical use of ketamine to inform policy and practical decisions: mixed-methods study. BJPsych Open 2019; 5:e62. [PMID: 31530293 PMCID: PMC6669880 DOI: 10.1192/bjo.2019.52] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Only one-third of patients with major depressive disorder achieve remission. One new and promising treatment, ketamine, may prove challenging to implement because of its abuse potential. Although clinicians' views have been sought, we need patients' views before large scale roll-out is considered. AIMS To explore patients' and carers' views to inform policy and practical decisions about the clinical use of ketamine. METHOD We carried out a mixed-methods study using data from 44 participants in 21 focus groups in three sessions and an online survey with patients, carers and advocates during a consultation day. Focus groups explored participant's views about ketamine as a form of treatment and the best way for ketamine to be prescribed and monitored. The qualitative data were analysed by two patient-researchers using an exploratory framework analysis and was supplemented by a survey. RESULTS The ten themes generated were monitoring, information, effect on daily life, side-effects, recreational use, effectiveness, appropriate support, cost, stigma and therapy. Participants wanted better evidence on the safety of ketamine after long-term use and felt that monitoring was required. Collecting this information would provide evidence for ketamine's safe use and administration. There were, however, concerns about the misuse of this information. Practical issues of access were important: repeated travelling to clinics and a lack of sufficiently informed medical staff were key barriers. CONCLUSIONS Clinicians have some similar and some different views to those of patients, carers and advocates, which need to be considered in any future roll-out of ketamine. DECLARATION OF INTEREST R.M. has had UK National Institute for Health Research grant funding to study ketamine, is participating in trials of esketamine, runs a clinic that provides ketamine treatment, and has consulted for Johnson & Johnson and Eleusis.
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Affiliation(s)
- Sagar Jilka
- Post-doctoral Research Associate and Patient and Public Involvement Coordinator, Institute of Psychiatry, Psychology & Neuroscience, King's College London; and South London and Maudsley NHS Foundation Trust, UK
| | - Claire Murray
- Patient and Public Involvement Manager, Oxford Health NHS Foundation Trust, Warneford Hospital, UK
| | - Ania Wieczorek
- Service User Research Assistant, Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK
| | - Helena Griffiths
- Service User Research Assistant, Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK
| | - Til Wykes
- Professor of Clinical Psychology and Rehabilitation and Vice Dean Psychology and System Sciences, Institute of Psychology, Psychiatry & Neuroscience, King's College London; and Consultant Clinical Psychologist, South London and Maudsley NHS Foundation Trust, UK
| | - Rupert McShane
- Associate Professor, Department of Psychiatry, University of Oxford; and Consultant Psychiatrist, Oxford Health NHS Trust, Warneford Hospital, Oxford, UK
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Abstract
BACKGROUND Memantine is a moderate affinity uncompetitive antagonist of glutamate NMDA receptors. It is licensed for use in moderate and severe Alzheimer's disease (AD); in the USA, it is also widely used off-label for mild AD. OBJECTIVES To determine efficacy and safety of memantine for people with dementia. To assess whether memantine adds benefit for people already taking cholinesterase inhibitors (ChEIs). SEARCH METHODS We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's register of trials (http://www.medicine.ox.ac.uk/alois/) up to 25 March 2018. We examined clinical trials registries, press releases and posters of memantine manufacturers; and the web sites of the FDA, EMEA and NICE. We contacted authors and companies for missing information. SELECTION CRITERIA Double-blind, parallel group, placebo-controlled, randomised trials of memantine in people with dementia. DATA COLLECTION AND ANALYSIS We pooled and analysed data from four clinical domains across different aetiologies and severities of dementia and for AD with agitation. We assessed the impact of study duration, severity and concomitant use of ChEIs. Consequently, we restricted analyses to the licensed dose (20 mg/day or 28 mg extended release) and data at six to seven months duration of follow-up, and analysed separately results for mild and moderate-to-severe AD.We transformed results for efficacy outcomes into the difference in points on particular outcome scales. MAIN RESULTS Across all types of dementia, data were available from almost 10,000 participants in 44 included trials, most of which were at low or unclear risk of bias. For nearly half the studies, relevant data were obtained from unpublished sources. The majority of trials (29 in 7885 participants) were conducted in people with AD.1. Moderate-to-severe AD (with or without concomitant ChEIs). High-certainty evidence from up to 14 studies in around 3700 participants consistently shows a small clinical benefit for memantine versus placebo: clinical global rating (CGR): 0.21 CIBIC+ points (95% confidence interval (CI) 0.14 to 0.30); cognitive function (CF): 3.11 Severe Impairment Battery (SIB) points (95% CI 2.42 to 3.92); performance on activities of daily living (ADL): 1.09 ADL19 points (95% CI 0.62 to 1.64); and behaviour and mood (BM): 1.84 Neuropsychiatric Inventory (NPI) points (95% CI 1.05 to 2.76). There may be no difference in the number of people discontinuing memantine compared to placebo: risk ratio (RR) 0.93 (95% CI 0.83 to 1.04) corresponding to 13 fewer people per 1000 (95% CI 31 fewer to 7 more). Although there is moderate-certainty evidence that fewer people taking memantine experience agitation as an adverse event: RR 0.81 (95% CI 0.66 to 0.99) (25 fewer people per 1000, 95% CI 1 to 44 fewer), there is also moderate-certainty evidence, from three additional studies, suggesting that memantine is not beneficial as a treatment for agitation (e.g. Cohen Mansfield Agitation Inventory: clinical benefit of 0.50 CMAI points, 95% CI -3.71 to 4.71) .The presence of concomitant ChEI does not impact on the difference between memantine and placebo, with the possible exceptions of the BM outcome (larger effect in people taking ChEIs) and the CF outcome (smaller effect).2. Mild AD (Mini Mental State Examination (MMSE) 20 to 23): mainly moderate-certainty evidence based on post-hoc subgroups from up to four studies in around 600 participants suggests there is probably no difference between memantine and placebo for CF: 0.21 ADAS-Cog points (95% CI -0.95 to 1.38); performance on ADL: -0.07 ADL 23 points (95% CI -1.80 to 1.66); and BM: -0.29 NPI points (95% CI -2.16 to 1.58). There is less certainty in the CGR evidence, which also suggests there may be no difference: 0.09 CIBIC+ points (95% CI -0.12 to 0.30). Memantine (compared with placebo) may increase the numbers of people discontinuing treatment because of adverse events (RR 2.12, 95% CI 1.03 to 4.39).3. Mild-to-moderate vascular dementia. Moderate- and low-certainty evidence from two studies in around 750 participants indicates there is probably a small clinical benefit for CF: 2.15 ADAS-Cog points (95% CI 1.05 to 3.25); there may be a small clinical benefit for BM: 0.47 NOSGER disturbing behaviour points (95% CI 0.07 to 0.87); there is probably no difference in CGR: 0.03 CIBIC+ points (95% CI -0.28 to 0.34); and there may be no difference in ADL: 0.11 NOSGER II self-care subscale points (95% CI -0.35 to 0.54) or in the numbers of people discontinuing treatment: RR 1.05 (95% CI 0.83 to 1.34).There is limited, mainly low- or very low-certainty efficacy evidence for other types of dementia (Parkinson's disease and dementia Lewy bodies (for which CGR may show a small clinical benefit; four studies in 319 people); frontotemporal dementia (two studies in 133 people); and AIDS-related Dementia Complex (one study in 140 people)).There is high-certainty evidence showing no difference between memantine and placebo in the proportion experiencing at least one adverse event: RR 1.03 (95% CI 1.00 to 1.06); the RR does not differ between aetiologies or severities of dementia. Combining available data from all trials, there is moderate-certainty evidence that memantine is 1.6 times more likely than placebo to result in dizziness (6.1% versus 3.9%), low-certainty evidence of a 1.3-fold increased risk of headache (5.5% versus 4.3%), but high-certainty evidence of no difference in falls. AUTHORS' CONCLUSIONS We found important differences in the efficacy of memantine in mild AD compared to that in moderate-to-severe AD. There is a small clinical benefit of memantine in people with moderate-to-severe AD, which occurs irrespective of whether they are also taking a ChEI, but no benefit in people with mild AD.Clinical heterogeneity in AD makes it unlikely that any single drug will have a large effect size, and means that the optimal drug treatment may involve multiple drugs, each having an effect size that may be less than the minimum clinically important difference.A definitive long-duration trial in mild AD is needed to establish whether starting memantine earlier would be beneficial over the long term and safe: at present the evidence is against this, despite it being common practice. A long-duration trial in moderate-to-severe AD is needed to establish whether the benefit persists beyond six months.
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Affiliation(s)
- Rupert McShane
- University of OxfordRadcliffe Department of MedicineJohn Radcliffe HospitalLevel 4, Main Hospital, Room 4401COxfordOxfordshireUKOX3 9DU
| | - Maggie J Westby
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Emmert Roberts
- King's College LondonDepartment of Psychological Medicine and National Addiction CentreWeston Education CentreLondonLondonUKSE5 9RJ
| | - Neda Minakaran
- Moorfields Eye Hospital NHS Foundation TrustDepartment of Ophthalmology162 City RoadLondonUKEC1V 2PD
| | - Lon Schneider
- Keck School of Medicine of the University of Southern California1540 Alcazar Street, CHP 216Los AngelesCAUSA90033
| | - Lucy E Farrimond
- Oxford University Hospitals NHS Foundation TrustNeurosciences DepartmentJohn Radcliffe HospitalOxfordUKOX3 9DU
| | - Nicola Maayan
- CochraneCochrane ResponseSt Albans House57‐59 HaymarketLondonUKSW1Y 4QX
| | - Jennifer Ware
- University of OxfordCochrane Dementia and Cognitive Improvement GroupOxfordUKOX3 9DU
| | - Jean Debarros
- University of OxfordNuffield Department of Clinical Neurosciences (NDCN)Level 6, West Wing, John Radcliffe HospitalOxfordUKOX3 9DU
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Hendry K, Green C, McShane R, Noel‐Storr AH, Stott DJ, Anwer S, Sutton AJ, Burton JK, Quinn TJ. AD-8 for detection of dementia across a variety of healthcare settings. Cochrane Database Syst Rev 2019; 3:CD011121. [PMID: 30828783 PMCID: PMC6398085 DOI: 10.1002/14651858.cd011121.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Dementia assessment often involves initial screening, using a brief tool, followed by more detailed assessment where required. The AD-8 is a short questionnaire, completed by a suitable 'informant' who knows the person well. AD-8 is designed to assess change in functional performance secondary to cognitive change. OBJECTIVES To determine the diagnostic accuracy of the informant-based AD-8 questionnaire, in detection of all-cause (undifferentiated) dementia in adults. Where data were available, we described the following: the diagnostic accuracy of the AD-8 at various predefined threshold scores; the diagnostic accuracy of the AD-8 for each healthcare setting and the effects of heterogeneity on the reported diagnostic accuracy of the AD-8. SEARCH METHODS We searched the following sources on 27 May 2014, with an update to 7 June 2018: ALOIS (Cochrane Dementia and Cognitive Improvement Group), MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), BIOSIS Previews (Thomson Reuters Web of Science), Web of Science Core Collection (includes Conference Proceedings Citation Index) (Thomson Reuters Web of Science), CINAHL (EBSCOhost) and LILACS (BIREME). We checked reference lists of relevant studies and reviews, used searches of known relevant studies in PubMed to track related articles, and contacted research groups conducting work on the AD-8 to try to find additional studies. We developed a sensitive search strategy and used standardised database subject headings as appropriate. Foreign language publications were translated. SELECTION CRITERIA We selected those studies which included the AD-8 to assess for the presence of dementia and where dementia diagnosis was confirmed with clinical assessment. We only included those studies where the AD-8 was used as an informant assessment. We made no exclusions in relation to healthcare setting, language of AD-8 or the AD-8 score used to define a 'test positive' case. DATA COLLECTION AND ANALYSIS We screened all titles generated by electronic database searches, and reviewed abstracts of potentially relevant studies. Two independent assessors checked full papers for eligibility and extracted data. We extracted data into two-by-two tables to allow calculation of accuracy metrics for individual studies. We then created summary estimates of sensitivity, specificity and likelihood ratios using the bivariate approach and plotting results in receiver operating characteristic (ROC) space. We determined quality assessment (risk of bias and applicability) using the QUADAS-2 tool. MAIN RESULTS From 36 papers describing AD-8 test accuracy, we included 10 papers. We utilised data from nine papers with 4045 individuals, 1107 of whom (27%) had a clinical diagnosis of dementia. Pooled analysis of seven studies, using an AD-8 informant cut-off score of two, indicated that sensitivity was 0.92 (95% confidence interval (CI) 0.86 to 0.96); specificity was 0.64 (95% CI 0.39 to 0.82); the positive likelihood ratio was 2.53 (95% CI 1.38 to 4.64); and the negative likelihood ratio was 0.12 (95% CI 0.07 to 0.21). Pooled analysis of five studies, using an AD-8 informant cut-off score of three, indicated that sensitivity was 0.91 (95% CI 0.80 to 0.96); specificity was 0.76 (95% CI 0.57 to 0.89); the positive likelihood ratio was 3.86 (95% CI 2.03 to 7.34); and the negative likelihood ratio was 0.12 (95% CI 0.06 to 0.24).Four studies were conducted in community settings; four were in secondary care (one in the acute hospital); and one study was in primary care. The AD-8 has a higher relative sensitivity (1.11, 95% CI 1.02 to 1.21), but lower relative specificity (0.51, 95% CI 0.23 to 1.09) in secondary care compared to community care settings.There was heterogeneity across the included studies. Dementia prevalence rate varied from 12% to 90% of included participants. The tool was also used in various different languages. Among all the included studies there was evidence of risk of bias. Issues included the selection of participants, conduct of index test, and flow of assessment procedures. AUTHORS' CONCLUSIONS The high sensitivity of the AD-8 suggests it can be used to identify adults who may benefit from further specialist assessment and diagnosis, but is not a diagnostic test in itself. This pattern of high sensitivity and lower specificity is often suited to a screening test. Test accuracy varies by setting, however data in primary care and acute hospital settings are limited. This review identified significant heterogeneity and risk of bias, which may affect the validity of its summary findings.
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Affiliation(s)
- Kirsty Hendry
- University of GlasgowInstitute of Cardiovascular and Medical SciencesNew Lister BuildingGlasgow Royal InfirmaryGlasgowUKG4 OSF
| | - Claire Green
- University of GlasgowInstitute of Cardiovascular and Medical SciencesNew Lister BuildingGlasgow Royal InfirmaryGlasgowUKG4 OSF
| | - Rupert McShane
- University of OxfordRadcliffe Department of MedicineJohn Radcliffe HospitalLevel 4, Main Hospital, Room 4401COxfordOxfordshireUKOX3 9DU
| | - Anna H Noel‐Storr
- University of OxfordRadcliffe Department of MedicineJohn Radcliffe HospitalLevel 4, Main Hospital, Room 4401COxfordOxfordshireUKOX3 9DU
| | - David J Stott
- University of GlasgowInstitute of Cardiovascular and Medical SciencesNew Lister BuildingGlasgow Royal InfirmaryGlasgowUKG4 OSF
| | - Sumayya Anwer
- University of BristolPopulation Health Sciences, Bristol Medical SchoolCanynge Hall, 39 Whatley RoadBristolUKBS8 2PS
| | - Alex J Sutton
- University of LeicesterDepartment of Health Sciences2nd Floor (Room 214e),Adrian BuildingLeicesterUKLE1 7RH
| | - Jennifer K Burton
- University of GlasgowAcademic Geriatric Medicine, Institute of Cardiovascular and Medical SciencesNew Lister Building, Glasgow Royal InfirmaryGlasgowUKG4 0SF
| | - Terry J Quinn
- University of GlasgowInstitute of Cardiovascular and Medical SciencesNew Lister BuildingGlasgow Royal InfirmaryGlasgowUKG4 OSF
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Drozdowska BA, MacKinnon S, Hamilton M, Noel-Storr AH, McShane R, Quinn T. 57ARE METHODOLOGICAL QUALITY AND COMPLETENESS OF REPORTING ASSOCIATED WITH CITATION-BASED MEASURES OF PUBLICATION IMPACT? A SECONDARY ANALYSIS OF A SYSTEMATIC REVIEW OF DEMENTIA BIOMARKER STUDIES. Age Ageing 2018. [DOI: 10.1093/ageing/afy127.06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Veraart JKE, Smith-Apeldoorn SY, Trueman H, de Boer MK, Schoevers RA, McShane R. Characteristics of patients expressing an interest in ketamine treatment: results of an online survey. BJPsych Open 2018; 4:389-392. [PMID: 30202601 PMCID: PMC6127959 DOI: 10.1192/bjo.2018.51] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 08/03/2018] [Accepted: 08/03/2018] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Off-label ketamine treatment has shown acute antidepressant effects that offer hope for patients with therapy-resistant depression. However, its potential for integration into treatment algorithms is controversial, not least because the evidence base for maintenance treatment with repeated ketamine administration is currently weak. Ketamine is also a drug of misuse, which has raised concerns regarding the target population. Little is known about which patients would seek ketamine treatment if it were more widely available. AIMS To explore some of the characteristics of the patients actively seeking ketamine treatment. METHOD An online survey containing questions about duration of current depressive episode, number of antidepressants used and other comments was completed by patients who were exploring the internet regarding the possibility of ketamine for depression. RESULTS Of the 1088 people who registered their interest, 93.3% reported depression, 64.3% reported a chronic course of their symptoms and in the past 10 years, 86.3% had tried at least two antidepressants. Desperation was a common theme, but this appeared to be competently expressed. A small minority (<8%) reported experience of illegal ketamine use. CONCLUSIONS It cannot be ruled out that patients with different degrees of treatment resistance and comorbidities will seek treatment with ketamine. This stresses the urgency to perform larger randomised controlled trials as well as to systematically monitor outcomes and adverse effects of ketamine, that is currently prescribed off-label for patients in need. DECLARATION OF INTEREST R.M. is consulting and is Principal Investigator for Janssen trials of esketamine and is consulting for Eleusis.
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Affiliation(s)
- Jolien K E Veraart
- Department of Psychiatry, University Medical Center Groningen and Research School Behavioral and Cognitive Neurosciences, University of Groningen, the Netherlands
| | - Sanne Y Smith-Apeldoorn
- Department of Psychiatry, University Medical Center Groningen and Research School Behavioral and Cognitive Neurosciences, University of Groningen, the Netherlands
| | - Hayley Trueman
- Clinical Practitioner, Oxford Health NHS Foundation Trust and Department of Psychiatry, University of Oxford, UK
| | - Marrit K de Boer
- Psychiatrist, Department of Psychiatry, University Medical Center Groningen and Research School Behavioral and Cognitive Neurosciences, University of Groningen, the Netherlands
| | - Robert A Schoevers
- Professor, Department of Psychiatry, University Medical Center Groningen and Research School Behavioral and Cognitive Neurosciences, University of Groningen, the Netherlands
| | - Rupert McShane
- Clinical Practitioner, Oxford Health NHS Foundation Trust and Associate Professor, Department of Psychiatry, University of Oxford, UK
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Mackinnon S, Drozdowska BA, Hamilton M, Noel-Storr AH, McShane R, Quinn T. Are methodological quality and completeness of reporting associated with citation-based measures of publication impact? A secondary analysis of a systematic review of dementia biomarker studies. BMJ Open 2018; 8:e020331. [PMID: 29572396 PMCID: PMC5875624 DOI: 10.1136/bmjopen-2017-020331] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVE To determine whether methodological and reporting quality are associated with surrogate measures of publication impact in the field of dementia biomarker studies. METHODS We assessed dementia biomarker studies included in a previous systematic review in terms of methodological and reporting quality using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) and Standards for Reporting of Diagnostic Accuracy (STARD), respectively. We extracted additional study and journal-related data from each publication to account for factors shown to be associated with impact in previous research. We explored associations between potential determinants and measures of publication impact in univariable and stepwise multivariable linear regression analyses. OUTCOME MEASURES We aimed to collect data on four measures of publication impact: two traditional measures-average number of citations per year and 5-year impact factor of the publishing journal and two alternative measures-the Altmetric Attention Score and counts of electronic downloads. RESULTS The systematic review included 142 studies. Due to limited data, Altmetric Attention Scores and electronic downloads were excluded from the analysis, leaving traditional metrics as the only analysed outcome measures. We found no relationship between QUADAS and traditional metrics. Citation rates were independently associated with 5-year journal impact factor (β=0.42; p<0.001), journal subject area (β=0.39; p<0.001), number of years since publication (β=-0.29; p<0.001) and STARD (β=0.13; p<0.05). Independent determinants of 5-year journal impact factor were citation rates (β=0.45; p<0.001), statement on conflict of interest (β=0.22; p<0.01) and baseline sample size (β=0.15; p<0.05). CONCLUSIONS Citation rates and 5-year journal impact factor appear to measure different dimensions of impact. Citation rates were weakly associated with completeness of reporting, while neither traditional metric was related to methodological rigour. Our results suggest that high publication usage and journal outlet is not a guarantee of quality and readers should critically appraise all papers regardless of presumed impact.
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Affiliation(s)
| | - Bogna A Drozdowska
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | | | - Rupert McShane
- Cochrane Dementia and Cognitive Improvement Group, Oxford, UK
| | - Terry Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Caddy C, Amit BH, McCloud TL, Rendell JM, Furukawa TA, McShane R, Hawton K, Cipriani A. Ketamine and other glutamate receptor modulators for depression in adults. BJPsych advances 2018. [DOI: 10.1192/apt.22.4.214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Considering the ample evidence of involvement of the glutamate system in the pathophysiology of depression, pre-clinical and clinical studies have been conducted to assess the antidepressant efficacy of glutamate inhibition, and glutamate receptor modulators in particular. This review focuses on the use of glutamate receptor modulators in unipolar depression.
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McShane R, Rowe D, Julier D. Will the information recorded in psychiatric notes change when patients have the right to read them? Psychiatr bull 2018. [DOI: 10.1192/pb.16.7.404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Psychiatric patients have had the right to see their notes from 1 November 1991. The ‘Access to Health Records Act (1990)’ makes provision for certain parts of the record to be exempt, including information which may cause serious mental or physical harm to the patient or anyone else. In addition, patients should not have access to information given by third party informants unless appropriate consent has been obtained. The legislation only applies to records made after 1 November 1991. It does not cover informal arrangements where written application for access is not made.
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Cubbin S, Pearce J, Bullock R, McShane R. Training and assessing independent nurse prescribers: a model for old age psychiatry. Psychiatr bull 2018. [DOI: 10.1192/pb.bp.108.020156] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Aims and MethodThe brevity of training and assessment for independent nurse prescribers has caused some concern. We aimed to validate an Objective Structured Clinical Examination (OSCE) for potential nurse prescribers in dementia. Nurses' performance after 12 days of training for potential prescribers was compared with that of doctors of different grades.ResultsThe performance of doctors, but not nurses, correlated with years of experience. Many nurses, especially those working in memory clinics, scored better than junior doctors.Clinical ImplicationsThis OSCE provides evidence of potential prescribers' competency for employers. This could make a significant contribution to maintaining high standards of patient safety with nurse prescribing. This may also be an appropriate addition to the assessment of specialty trainees as well as for revalidation.
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Knapp M, King D, Romeo R, Adams J, Baldwin A, Ballard C, Banerjee S, Barber R, Bentham P, Brown RG, Burns A, Dening T, Findlay D, Holmes C, Johnson T, Jones R, Katona C, Lindesay J, Macharouthu A, McKeith I, McShane R, O'Brien JT, Phillips PPJ, Sheehan B, Howard R. Cost-effectiveness of donepezil and memantine in moderate to severe Alzheimer's disease (the DOMINO-AD trial). Int J Geriatr Psychiatry 2017; 32:1205-1216. [PMID: 27739182 PMCID: PMC5724694 DOI: 10.1002/gps.4583] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 08/25/2016] [Accepted: 08/25/2016] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Most investigations of pharmacotherapy for treating Alzheimer's disease focus on patients with mild-to-moderate symptoms, with little evidence to guide clinical decisions when symptoms become severe. We examined whether continuing donepezil, or commencing memantine, is cost-effective for community-dwelling, moderate-to-severe Alzheimer's disease patients. METHODS Cost-effectiveness analysis was based on a 52-week, multicentre, double-blind, placebo-controlled, factorial clinical trial. A total of 295 community-dwelling patients with moderate/severe Alzheimer's disease, already treated with donepezil, were randomised to: (i) continue donepezil; (ii) discontinue donepezil; (iii) discontinue donepezil and start memantine; or (iv) continue donepezil and start memantine. RESULTS Continuing donepezil for 52 weeks was more cost-effective than discontinuation, considering cognition, activities of daily living and health-related quality of life. Starting memantine was more cost-effective than donepezil discontinuation. Donepezil-memantine combined is not more cost-effective than donepezil alone. CONCLUSIONS Robust evidence is now available to inform clinical decisions and commissioning strategies so as to improve patients' lives whilst making efficient use of available resources. Clinical guidelines for treating moderate/severe Alzheimer's disease, such as those issued by NICE in England and Wales, should be revisited. © 2016 The Authors. International Journal of Geriatric Psychiatry published by John Wiley & Sons Ltd.
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Affiliation(s)
- Martin Knapp
- Personal Social Services Research UnitLondon School of Economics and Political ScienceLondonUK
| | - Derek King
- Personal Social Services Research UnitLondon School of Economics and Political ScienceLondonUK
| | - Renée Romeo
- King's Health EconomicsInstitute of Psychiatry, Psychology and Neuroscience, King's College LondonLondonUK
| | - Jessica Adams
- Department of BiostaticsInstitute of Psychiatry, Psychology and Neuroscience, King's College LondonLondonUK
| | - Ashley Baldwin
- Five Boroughs Partnership NHS Foundation TrustWarringtonUK
| | - Clive Ballard
- Wolfson Centre for Age Related DisordersKing's College, LondonLondonUK
| | - Sube Banerjee
- Brighton and Sussex Medical SchoolUniversity of SussexBrightonUK
| | | | - Peter Bentham
- Birmingham and Solihull Mental Health NHS Foundation TrustBirminghamUK
| | - Richard G Brown
- Department of PsychologyInstitute of Psychiatry, Psychology and Neuroscience, King's College LondonLondonUK
| | - Alistair Burns
- Faculty of Medical and Human SciencesInstitute of Brain, Behaviour and Mental Health, University of ManchesterManchesterUK
| | - Tom Dening
- Division of Psychiatry and Applied PsychologyUniversity of NottinghamNottinghamUK
| | | | - Clive Holmes
- Faculty of MedicineUniversity of SouthamptonSouthamptonUK
| | - Tony Johnson
- Medical Research Council Clinical Trials UnitUniversity College LondonLondonUK
| | - Robert Jones
- Division of Psychiatry and Applied PsychologyUniversity of NottinghamNottinghamUK
| | | | | | - Ajay Macharouthu
- Ayrshire and Arran NHSUniversity Hospital CrosshouseKilmarnockUK
| | - Ian McKeith
- Institute for AgeingUniversity of NewcastleNewcastle upon TyneUK
| | - Rupert McShane
- Oxford Health NHS Foundation TrustWarneford HospitalOxfordUK
| | - John T O'Brien
- Department of PsychiatryUniversity of CambridgeCambridgeUK
| | | | - Bart Sheehan
- Oxford University Hospitals NHS Foundation TrustOxfordUK
| | - Robert Howard
- Division of PsychiatryUniversity College LondonLondonUK
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Knight F, Ridge D, McShane R, Ryan S, Griffith L. Care, Control, and the Electroconvulsive Therapy Ritual: Making Sense of Polarized Patient Narratives. Qual Health Res 2017; 27:1675-1685. [PMID: 28799472 DOI: 10.1177/1049732317701403] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Despite evidence of short-term effectiveness of ECT (electroconvulsive therapy), both positive and negative patient reports are common. However, research examining these polarized accounts has not adequately elucidated why such divergences occur. We thus sought to examine opposing patient narratives to better understand underlying meanings. Eighteen interviews were conducted with U.K.-based people who had experienced the treatment. Our analysis revealed that the quality of relations with staff, ECT artifacts (e.g., the ECT suite), and perceived outcomes all play a role in divergent accounts. Positive reflections on ECT emerged alongside narratives of trust in staff, comfort with ECT, and perception of sufficient personal control. Conversely, where negative evaluations of ECT predominated, there was anger associated with a lack of control, a belief that ECT made little sense, and was linked to past abuses and/or the unacceptability of side effects. We discuss the implications of our findings for professionals.
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Affiliation(s)
- Fauzia Knight
- 1 Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - Damien Ridge
- 2 University of Westminster, London, United Kingdom
| | - Rupert McShane
- 1 Department of Psychiatry, University of Oxford, Oxford, United Kingdom
- 4 Oxford Health NHS Foundation Trust, Warneford Hospital, UK
| | - Sara Ryan
- 1 Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - Laura Griffith
- 3 University of Birmingham, Birmingham, West Midlands, United Kingdom
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Singh I, Morgan C, Curran V, Nutt D, Schlag A, McShane R. Ketamine treatment for depression: opportunities for clinical innovation and ethical foresight. Lancet Psychiatry 2017; 4:419-426. [PMID: 28395988 DOI: 10.1016/s2215-0366(17)30102-5] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 11/15/2016] [Accepted: 11/16/2016] [Indexed: 12/12/2022]
Abstract
We present a review and analysis of the ethical considerations in off-label ketamine use for severe, treatment-resistant depression. The analysis of ethical considerations is contextualised in an overview of the evidence for ketamine use in depression, and a review of the drug's safety profile. We find that, based on current evidence, ketamine use for severe, treatment-resistant depression does not violate ethical principles; however, clinicians and professional bodies must take steps to ensure that guidelines for good practice are enacted, that all experimental and trial data are made available through national registries, and that the risk potential of ketamine treatment continues to be monitored and modelled. We conclude with a set of key recommendations for oversight bodies that would support safe, effective, and ethical use of ketamine in depression.
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Affiliation(s)
- Ilina Singh
- Department of Psychiatry and Oxford Uehiro Centre, University of Oxford, Oxford, UK.
| | - Celia Morgan
- Department of Psychology, University of Exeter, Exeter, UK
| | - Valerie Curran
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - David Nutt
- Centre for Neuropsychopharmacology, Division of Brain Sciences, Imperial College London, London, UK
| | | | - Rupert McShane
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
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Harrison JK, Stott DJ, McShane R, Noel‐Storr AH, Swann‐Price RS, Quinn TJ. Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) for the early diagnosis of dementia across a variety of healthcare settings. Cochrane Database Syst Rev 2016; 11:CD011333. [PMID: 27869298 PMCID: PMC6477966 DOI: 10.1002/14651858.cd011333.pub2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) is a structured interview based on informant responses that is used to assess for possible dementia. IQCODE has been used for retrospective or contemporaneous assessment of cognitive decline. There is considerable interest in tests that may identify those at future risk of developing dementia. Assessing a population free of dementia for the prospective development of dementia is an approach often used in studies of dementia biomarkers. In theory, questionnaire-based assessments, such as IQCODE, could be used in a similar way, assessing for dementia that is diagnosed on a later (delayed) assessment. OBJECTIVES To determine the diagnostic accuracy of IQCODE in a population free from dementia for the delayed diagnosis of dementia (test accuracy with delayed verification study design). SEARCH METHODS We searched these sources on 16 January 2016: ALOIS (Cochrane Dementia and Cognitive Improvement Group), MEDLINE Ovid SP, Embase Ovid SP, PsycINFO Ovid SP, BIOSIS Previews on Thomson Reuters Web of Science, Web of Science Core Collection (includes Conference Proceedings Citation Index) on Thomson Reuters Web of Science, CINAHL EBSCOhost, and LILACS BIREME. We also searched sources specific to diagnostic test accuracy: MEDION (Universities of Maastricht and Leuven); DARE (Database of Abstracts of Reviews of Effects, in the Cochrane Library); HTA Database (Health Technology Assessment Database, in the Cochrane Library), and ARIF (Birmingham University). We checked reference lists of included studies and reviews, used searches of included studies in PubMed to track related articles, and contacted research groups conducting work on IQCODE for dementia diagnosis to try to find additional studies. We developed a sensitive search strategy; search terms were designed to cover key concepts using several different approaches run in parallel, and included terms relating to cognitive tests, cognitive screening, and dementia. We used standardised database subject headings, such as MeSH terms (in MEDLINE) and other standardised headings (controlled vocabulary) in other databases, as appropriate. SELECTION CRITERIA We selected studies that included a population free from dementia at baseline, who were assessed with the IQCODE and subsequently assessed for the development of dementia over time. The implication was that at the time of testing, the individual had a cognitive problem sufficient to result in an abnormal IQCODE score (defined by the study authors), but not yet meeting dementia diagnostic criteria. DATA COLLECTION AND ANALYSIS We screened all titles generated by the electronic database searches, and reviewed abstracts of all potentially relevant studies. Two assessors independently checked the full papers for eligibility and extracted data. We determined quality assessment (risk of bias and applicability) using the QUADAS-2 tool, and reported quality using the STARDdem tool. MAIN RESULTS From 85 papers describing IQCODE, we included three papers, representing data from 626 individuals. Of this total, 22% (N = 135/626) were excluded because of prevalent dementia. There was substantial attrition; 47% (N = 295) of the study population received reference standard assessment at first follow-up (three to six months) and 28% (N = 174) received reference standard assessment at final follow-up (one to three years). Prevalence of dementia ranged from 12% to 26% at first follow-up and 16% to 35% at final follow-up.The three studies were considered to be too heterogenous to combine, so we did not perform meta-analyses to describe summary estimates of interest. Included patients were poststroke (two papers) and hip fracture (one paper). The IQCODE was used at three thresholds of positivity (higher than 3.0, higher than 3.12 and higher than 3.3) to predict those at risk of a future diagnosis of dementia. Using a cut-off of 3.0, IQCODE had a sensitivity of 0.75 (95%CI 0.51 to 0.91) and a specificity of 0.46 (95%CI 0.34 to 0.59) at one year following stroke. Using a cut-off of 3.12, the IQCODE had a sensitivity of 0.80 (95%CI 0.44 to 0.97) and specificity of 0.53 (95C%CI 0.41 to 0.65) for the clinical diagnosis of dementia at six months after hip fracture. Using a cut-off of 3.3, the IQCODE had a sensitivity of 0.84 (95%CI 0.68 to 0.94) and a specificity of 0.87 (95%CI 0.76 to 0.94) for the clinical diagnosis of dementia at one year after stroke.In generaI, the IQCODE was sensitive for identification of those who would develop dementia, but lacked specificity. Methods for both excluding prevalent dementia at baseline and assessing for the development of dementia were varied, and had the potential to introduce bias. AUTHORS' CONCLUSIONS Included studies were heterogenous, recruited from specialist settings, and had potential biases. The studies identified did not allow us to make specific recommendations on the use of the IQCODE for the future diagnosis of dementia in clinical practice. The included studies highlighted the challenges of delayed verification dementia research, with issues around prevalent dementia assessment, loss to follow-up over time, and test non-completion potentially limiting the studies. Future research should recognise these issues and have explicit protocols for dealing with them.
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Affiliation(s)
- Jennifer K Harrison
- University of EdinburghCentre for Cognitive Ageing and Cognitive Epidemiology and the Alzheimer Scotland Dementia Research CentreDepartment of Geriatric Medicine, The Royal Infirmary of Edinburgh, Room S164251 Little France CrescentEdinburghUKEH16 4SB
| | - David J Stott
- University of GlasgowInstitute of Cardiovascular and Medical SciencesNew Lister BuildingGlasgow Royal InfirmaryGlasgowStrathclydeUKG4 0SFR
| | - Rupert McShane
- University of OxfordRadcliffe Department of MedicineJohn Radcliffe HospitalLevel 4, Main Hospital, Room 4401COxfordOxfordshireUKOX3 9DU
| | - Anna H Noel‐Storr
- University of OxfordRadcliffe Department of MedicineJohn Radcliffe HospitalLevel 4, Main Hospital, Room 4401COxfordOxfordshireUKOX3 9DU
| | | | - Terry J Quinn
- University of GlasgowInstitute of Cardiovascular and Medical SciencesNew Lister BuildingGlasgow Royal InfirmaryGlasgowStrathclydeUKG4 0SFR
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McCloud TL, Caddy C, Jochim J, Rendell JM, Diamond PR, Shuttleworth C, Brett D, Amit BH, McShane R, Hamadi L, Hawton K, Cipriani A. Ketamine and other glutamate receptor modulators for depression in bipolar disorder in adults. BJPsych advances 2016. [DOI: 10.1192/apt.22.4.215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
There is emerging evidence that glutamatergic system dysfunction might play an important role in the pathophysiology of bipolar depression. This review focuses on the use of glutamate receptor modulators for depression in bipolar disorder.
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Malhi GS, Byrow Y, Cassidy F, Cipriani A, Demyttenaere K, Frye MA, Gitlin M, Kennedy SH, Ketter TA, Lam RW, McShane R, Mitchell AJ, Ostacher MJ, Rizvi SJ, Thase ME, Tohen M. Ketamine: stimulating antidepressant treatment? BJPsych Open 2016; 2:e5-e9. [PMID: 27703782 PMCID: PMC4995167 DOI: 10.1192/bjpo.bp.116.002923] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 03/29/2016] [Accepted: 03/31/2016] [Indexed: 12/16/2022] Open
Abstract
SUMMARY The appeal of ketamine - in promptly ameliorating depressive symptoms even in those with non-response - has led to a dramatic increase in its off-label use. Initial promising results await robust corroboration and key questions remain, particularly concerning its long-term administration. It is, therefore, timely to review the opinions of mood disorder experts worldwide pertaining to ketamine's potential as an option for treating depression and provide a synthesis of perspectives - derived from evidence and clinical experience - and to consider strategies for future investigations. DECLARATION OF INTERESTS G.S.M. Grant/research support: National Health Medical Research Council, NSW Health, Ramsay Health, American Foundation for Suicide Prevention, AstraZeneca, Eli Lilly & Co, Organon, Pfizer, Servier, and Wyeth; has been a speaker for Abbott, AstraZeneca, Eli Lilly & Co, Janssen Cilag, Lundbeck, Pfizer, Ranbaxy, Servier, and Wyeth; consultant: AstraZeneca, Eli Lilly & Co, Janssen Cilag, Lundbeck, and Servier. M.A.F. Grant support: AssureRx, Janssen Research & Development, Mayo Foundation, Myriad, National Institute of Alcohol Abuse and Alcoholism (NIAAA), National Institute of Mental Health (NIMH), Pfizer. Consultant (Mayo): Janssen Research & Development, LLC, Mitsubishi Tanabe Pharma Corporation, Myriad Genetics, Neuralstem Inc., Sunovion, Supernus Pharmaceuticals, Teva Pharmaceuticals. CME/travel support: American Physician Institute, CME Outfitters. Financial interest/Mayo Clinic 2016: AssureRx. S.H.K. Grant/research support: Brain Canada, Bristol Meyer Squibb, CIHR, Janssen, Johnson & Johnson, Lundbeck, Ontario Brain Institute, Pfizer, Servier, St. Jude Medical, Sunovion. T.A.K. Grant/research support (through Stanford University): Sunovion Pharmaceuticals and Merck & Co., Inc.; consultant/advisory board bember: Allergan, Inc., Janssen Pharmaceuticals, Myriad Genetic Laboratories, Inc., and Sunovion Pharmaceuticals; lecture honoraria (not Speaker's Bureau payments): GlaxoSmithKline, and Sunovion Pharmaceuticals; royalties from American Psychiatric Publishing, Inc. Also, AstraZeneca Pharmaceuticals LP provided publication support to Parexel for preparation of a manuscript. Spouse employee and stockholder of Janssen Pharmaceuticals. R.W.L. Honoraria for speaking/advising/consulting, and/or received research funds: AstraZeneca, Brain Canada, Bristol Myers Squibb, Canadian Institutes of Health Research, Canadian Depression Research and Intervention Network, Canadian Network for Mood and Anxiety Treatments, Canadian Psychiatric Association, Coast Capital Savings, Johnson and Johnson, Lundbeck, Lundbeck Institute, Pfizer, Servier, St. Jude Medical, Takeda University, Health Network Foundation, and Vancouver Coastal Health Research Institute. R.M. Investigator Janssen trials of esketamine; 'paid-for' ketamine clinic operated by Oxford Health NHS Foundation Trust - fees used to support the Trust. M.J.O. Consultant: Sunovion and Acadia Pharmaceuticals. Full-time employee of U.S. Department of Veterans Affairs. M.E.T. Advisory/Consultant: Alkermes, Allergan, AstraZeneca, Bristol-Myers Squibb Company, Cerecor inc., Eli Lilly & Co., Forest Laboratories, Gerson Lehrman Group, Fabre-Kramer Pharmaceuticals, Inc., GlaxoSmithKline, Guidepoint Global, H. Lundbeck A/S, MedAvante Inc., Merck and Co. Inc. (formerly Schering Plough and Organon), Moksha8, Naurex Inc., Neuronetics Inc., Novartis, Ortho-McNeil Pharmaceuticals (Johnson & Johnson; Janssen), Otsuka, Pamlab, L.L.C. (Nestle), Pfizer (formerly Wyeth Ayerst Pharmaceuticals), Shire US Inc., Sunovion Pharmaceuticals Inc., Trius Therapeutical Inc. and Takeda. Grant support: Agency for Healthcare Research and Quality, Alkermes, AssureRx, Avanir, Forest Pharmaceuticals, Janssen, National Institute of Mental Health, and Otsuka Pharmaceuticals. Speakers Bureau: None since June, 2010. Equity Holdings: MedAvante, Inc. Royalties: American Psychiatric Foundation, Guilford Publications, Herald House, W.W. Norton & Company, Inc. Spouse's employment: Peloton Advantage, which does business with Pfizer. M.T. Full-time employee at Lilly 1997 to 2008. Honoraria/consulted: Abbott, AstraZeneca, Bristol Myers Squibb, GlaxoSmithKline, Lilly, Johnson & Johnson, Allergan, Otsuka, Merck, Sunovion, Forest, Geodon Richter Plc, Roche, Elan, Alkermes, Lundbeck, Teva, Pamlab, Minerva, Wyeth and Wiley Publishing. Spouse was full time-employee at Lilly 1998-2013. COPYRIGHT AND USAGE © The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.
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Affiliation(s)
- Gin S Malhi
- , MD, Department of Psychiatry, Kolling Institute, Sydney Medical School, University of Sydney, Sydney, NSW, Australia; CADE Clinic, Department of Psychiatry, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Yulisha Byrow
- , PhD, CADE Clinic, Department of Psychiatry, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Frederick Cassidy
- , MD, Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - Andrea Cipriani
- , PhD, Department of Psychiatry, University of Oxford, Oxford, UK; Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Koen Demyttenaere
- , PhD, KU Leuven, Department of Neurosciences, Research Group of Psychiatry, University Psychiatric Center, Leuven, Belgium
| | - Mark A Frye
- , MD, Psychiatry, Mayo Clinic Depression Center, Mayo Clinic, Rochester, MN, USA
| | - Michael Gitlin
- , MD, Department of Psychiatry, Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Sidney H Kennedy
- , MD, Arthur Sommer Rotenberg Chair in Suicide & Depression Studies, St. Michael's Hospital; Professor of Psychiatry, University Health Network and Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Terence A Ketter
- , MD, Psychiatry and Behavioral Sciences, Chief, Bipolar Disorders Clinic, Stanford University School of Medicine, Stanford, CA, USA
| | - Raymond W Lam
- , MD, Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | | | - Alex J Mitchell
- , MD, Liaison Psychiatry and Psycho-Oncology, University of Leicester, Leicester, UK
| | - Michael J Ostacher
- , MD, Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Sakina J Rizvi
- , PhD, Li Ka Shing Knowledge Institute, ASR Suicide and Depression Studies Program, St. Michael's Hospital; Department of Psychiatry and Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Michael E Thase
- , MD, Department of Psychiatry, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA; Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Mauricio Tohen
- , MD, Professor and Chairman of the Department of Psychiatry & Behavioural Sciences at the University of New Mexico, Albuquerque, NM, USA
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Atherton N, Bridle C, Brown D, Collins H, Dosanjh S, Griffiths F, Hennings S, Khan K, Lall R, Lyle S, McShane R, Mistry D, Nichols V, Petrou S, Sheehan B, Slowther AM, Thorogood M, Withers E, Zeh P, Lamb SE. Dementia and Physical Activity (DAPA) - an exercise intervention to improve cognition in people with mild to moderate dementia: study protocol for a randomized controlled trial. Trials 2016; 17:165. [PMID: 27015659 PMCID: PMC4807539 DOI: 10.1186/s13063-016-1288-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 03/13/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Dementia is more common in older than in younger people, and as a result of the ageing of the population in developed countries, it is becoming more prevalent. Drug treatments for dementia are limited, and the main support offered to people with dementia and their families is generally services to mitigate against loss of function. Physical exercise is a candidate non-pharmacological treatment for dementia. METHODS/DESIGN DAPA is a randomised controlled trial funded by the National Institute for Health Research Health Technology Assessment programme to estimate the effect of a 4-month, moderate- to hard-intensity exercise training programme and subsequent advice to remain active, on cognition (primary outcome) at 12 months in people with mild to moderate dementia. Community-dwelling participants (with their carers where possible), who are able to walk 3 metres without human assistance, able to undertake an exercise programme and do not have any unstable or terminal illness are recruited. Participants are then randomised by an independent statistician using a computerised random number generator to usual care or exercise at a 2:1 ratio in favour of exercise. The exercise intervention comprises 29, 1-hour-long exercise classes, run twice weekly at suitable venues such as leisure centres, which include aerobic exercise (on static bikes) and resistance exercise (using weights). Goals for independent exercise are set while the classes are still running, and supported thereafter with phone calls. The primary outcome is measured using ADAS-cog. Secondary outcome measures include behavioural symptoms, functional ability, quality of life and carer burden. Primary and secondary outcomes will be measured at baseline and at 6 and 12 months after randomisation, by researchers masked to participant randomisation in the participants' own homes. An economic evaluation will be carried out in parallel to the RCT, as will a qualitative study capturing the experiences of participants, carers and staff delivering the intervention. DISCUSSION The DAPA study will be the first large, randomised trial of the cognitive effects of exercise on people with dementia. The intervention is designed to be capable of being delivered within the constraints of NHS service provision, and the economic evaluation will allow assessment of its cost-effectiveness. TRIAL REGISTRATION DAPA was registered with the ISRCTN database on 29 July 2011, registration number ISRCTN32612072 .
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Affiliation(s)
- Nicky Atherton
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK
| | - Chris Bridle
- Lincoln Institute for Health, University of Lincoln, Brayford Pool, Lincoln, LN6 7TS, UK
| | - Deborah Brown
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Kadoorie Centre, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK
| | - Helen Collins
- John Radcliffe Hospital, Oxford University Hospitals, Oxford, OX3 9DU, UK
| | - Sukhdeep Dosanjh
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK
| | - Frances Griffiths
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK
| | - Susie Hennings
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK
| | - Kamran Khan
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK
| | - Ranjit Lall
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK
| | - Samantha Lyle
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Kadoorie Centre, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK
| | - Rupert McShane
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK
| | - Dipesh Mistry
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK
| | - Vivien Nichols
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK
| | - Stavros Petrou
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK
| | - Bart Sheehan
- John Radcliffe Hospital, Oxford University Hospitals, Oxford, OX3 9DU, UK
| | - Anne-Marie Slowther
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK
| | - Margaret Thorogood
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK
| | - Emma Withers
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK
| | - Peter Zeh
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK
| | - Sarah E Lamb
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK. .,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Kadoorie Centre, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.
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Howard R, McShane R, Lindesay J, Ritchie C, Baldwin A, Barber R, Burns A, Dening T, Findlay D, Holmes C, Jones R, Jones R, McKeith I, Macharouthu A, O'Brien J, Sheehan B, Juszczak E, Katona C, Hills R, Knapp M, Ballard C, Brown RG, Banerjee S, Adams J, Johnson T, Bentham P, Phillips PPJ. Nursing home placement in the Donepezil and Memantine in Moderate to Severe Alzheimer's Disease (DOMINO-AD) trial: secondary and post-hoc analyses. Lancet Neurol 2015; 14:1171-81. [PMID: 26515660 DOI: 10.1016/s1474-4422(15)00258-6] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 09/21/2015] [Accepted: 09/25/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Findings from observational studies have suggested a delay in nursing home placement with dementia drug treatment, but findings from a previous randomised trial of patients with mild-to-moderate Alzheimer's disease showed no effect. We investigated the effects of continuation or discontinuation of donepezil and starting of memantine on subsequent nursing home placement in patients with moderate-to-severe Alzheimer's disease. METHODS In the randomised, double-blind, placebo-controlled Donepezil and Memantine in Moderate to Severe Alzheimer's Disease (DOMINO-AD) trial, community-living patients with moderate-to-severe Alzheimer's disease (who had been prescribed donepezil continuously for at least 3 months at a dose of 10 mg for at least the previous 6 weeks and had a score of between 5 and 13 on the Standardised Mini-Mental State Examination) were recruited from 15 secondary care memory centres in England and Scotland and randomly allocated to continue donepezil 10 mg per day without memantine, discontinue donepezil without memantine, discontinue donepezil and start memantine 20 mg per day, or continue donepezil 10 mg per day and start memantine 20 mg per day, for 52 weeks. After 52 weeks, choice of treatment was left to participants and their physicians. Place of residence was recorded during the first 52 weeks of the trial and then every 26 weeks for a further 3 years. A secondary outcome of the trial, reported in this study, was nursing home placement: an irreversible move from independent accommodation to a residential caring facility. Analyses restricted to risk of placement in the first year of follow-up after the patients had completed the double-blind phase of the trial were post-hoc. The DOMINO-AD trial is registered with the ISRCTN Registry, number ISRCTN49545035. FINDINGS Between Feb 11, 2008, and March 5, 2010, 73 (25%) patients were randomly assigned to continue donepezil without memantine, 73 (25%) to discontinue donepezil without memantine, 76 (26%) to discontinue donepezil and start memantine, and 73 (25%) to continue donepezil and start memantine. 162 (55%) patients underwent nursing home placement within 4 years of randomisation, with similar numbers for all groups (36 [49%] in patients who continued donepezil without memantine, 42 [58%] who discontinued donepezil without memantine, 41 [54%] who discontinued donepezil and started memantine, and 43 [59%] who continued donepezil and started memantine). We noted significant (p=0·010) heterogeneity of treatment effect over time, with significantly more nursing home placements in the combined donepezil discontinuation groups during the first year (hazard ratio 2·09 [95% CI 1·29-3·39]) than in the combined donepezil continuation groups, and no difference during the next 3 years (0·89 [0·58-1·35]). We noted no effect of patients starting memantine compared with not starting memantine during the first year (0·92 [0·58-1·45]) or the next 3 years (1·23 [0·81-1·87]). INTERPRETATION Withdrawal of donepezil in patients with moderate-to-severe Alzheimer's disease increased the risk of nursing home placement during 12 months of treatment, but made no difference during the following 3 years of follow-up. Decisions to stop or continue donepezil treatment should be informed by potential risks of withdrawal, even if the perceived benefits of continued treatment are not clear. FUNDING Medical Research Council and UK Alzheimer's Society.
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Affiliation(s)
- Robert Howard
- Division of Psychiatry, University College London, London, UK; Department of Old Age Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
| | - Rupert McShane
- Oxford Health NHS Foundation Trust, Warneford Hospital, Headington, Oxford, UK
| | | | - Craig Ritchie
- Centre for Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Ashley Baldwin
- Five Boroughs Partnership NHS Foundation Trust, Winwick, Warrington, UK
| | - Robert Barber
- Centre for Ageing and Vitality, Newcastle upon Tyne, UK
| | - Alistair Burns
- Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, UK
| | - Tom Dening
- Institute of Mental Health, University of Nottingham, Nottingham, UK
| | | | - Clive Holmes
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Robert Jones
- Department of Pyschiatry, University of Nottingham, Nottingham, UK
| | - Roy Jones
- Research Institute for the Care of Older People, Bath, UK
| | - Ian McKeith
- Newcastle; University Institute for Ageing, Newcastle University, Newcastle Upon Tyne, UK
| | - Ajay Macharouthu
- Ayrshire and Arran NHS, University Hospital Crosshouse, Crosshouse, Kilmarnock, UK
| | - John O'Brien
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Bart Sheehan
- Oxford University Hospitals NHS Trust, Headington, Oxford, UK
| | - Edmund Juszczak
- National Perinatal Epidemiology Unit Clinical Trials Unit, University of Oxford, Oxford, UK
| | | | - Robert Hills
- Cardiff University School of Medicine, Cardiff, UK
| | | | - Clive Ballard
- Wolfson Centre for Age Related Disorders, King's College London, London, UK
| | | | - Sube Banerjee
- Brighton and Sussex Medical School, University of Sussex, Brighton, East Sussex, UK
| | - Jessica Adams
- Department of Old Age Psychiatry, King's College London, London, UK
| | - Tony Johnson
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Peter Bentham
- Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | - Patrick P J Phillips
- Medical Research Council Clinical Trials Unit, University College London, London, UK
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Abstract
BACKGROUND People with Down syndrome are vulnerable to developing dementia at an earlier age than the general population. Alzheimer's disease and cognitive decline in people with Down syndrome can place a significant burden on both the person with Down syndrome and their family and carers. Various pharmacological interventions, including donepezil, galantamine, memantine and rivastigmine, appear to have some effect in treating cognitive decline in people without Down syndrome, but their effectiveness for those with Down syndrome remains unclear. OBJECTIVES To assess the effectiveness of anti-dementia pharmacological interventions and nutritional supplements for treating cognitive decline in people with Down syndrome. SEARCH METHODS In January 2015, we searched CENTRAL, ALOIS (the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group), Ovid MEDLINE, Embase, PsycINFO, seven other databases, and two trials registers. In addition, we checked the references of relevant reviews and studies and contacted study authors, other researchers and relevant drug manufacturers to identify additional studies. SELECTION CRITERIA Randomised controlled trials (RCTs) of anti-dementia pharmacological interventions or nutritional supplements for adults (aged 18 years and older) with Down syndrome, in which treatment was administered and compared with either placebo or no treatment. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the risk of bias of included trials and extracted the relevant data. Review authors contacted study authors to obtain missing information where necessary. MAIN RESULTS Only nine studies (427 participants) met the inclusion criteria for this review. Four of these (192 participants) assessed the effectiveness of donepezil, two (139 participants) assessed memantine, one (21 participants) assessed simvastatin, one study (35 participants) assessed antioxidants, and one study (40 participants) assessed acetyl-L-carnitine.Five studies focused on adults aged 45 to 55 years, while the remaining four studies focused on adults aged 20 to 29 years. Seven studies were conducted in either the USA or UK, one between Norway and the UK, and one in Japan. Follow-up periods in studies ranged from four weeks to two years. The reviewers judged all included studies to be at low or unclear risk of bias.Analyses indicate that for participants who received donepezil, scores in measures of cognitive functioning (standardised mean difference (SMD) 0.52, 95% confidence interval (CI) -0.27 to 1.13) and measures of behaviour (SMD 0.42, 95% CI -0.06 to 0.89) were similar to those who received placebo. However, participants who received donepezil were significantly more likely to experience an adverse event (odds ratio (OR) 0.32, 95% CI 0.16 to 0.62). The quality of this body of evidence was low. None of the included donepezil studies reported data for carer stress, institutional/home care, or death.For participants who received memantine, scores in measures of cognitive functioning (SMD 0.05, 95% CI -0.43 to 0.52), behaviour (SMD -0.17, 95% CI -0.46 to 0.11), and occurrence of adverse events (OR 0.45, 95% CI 0.18 to 1.17) were similar to those who received placebo. The quality of this body of evidence was low. None of the included memantine studies reported data for carer stress, institutional/home care, or death.Due to insufficient data, it was possible to provide a narrative account only of the outcomes for simvastatin, antioxidants, and acetyl-L-carnitine. Results from one pilot study suggest that participants who received simvastatin may have shown a slight improvement in cognitive measures. AUTHORS' CONCLUSIONS Due to the low quality of the body of evidence in this review, it is difficult to draw conclusions about the effectiveness of any pharmacological intervention for cognitive decline in people with Down syndrome.
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Affiliation(s)
- Nuala Livingstone
- Queen's University BelfastSchool of Sociology, Social Policy and Social Work6 College ParkBelfastUKBT7 1LP
| | - Jennifer Hanratty
- Queen's University BelfastSchool of Sociology, Social Policy and Social Work6 College ParkBelfastUKBT7 1LP
| | - Rupert McShane
- University of OxfordRadcliffe Department of MedicineJohn Radcliffe HospitalLevel 4, Main Hospital, Room 4401COxfordOxfordshireUKOX3 9DU
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McCloud TL, Caddy C, Jochim J, Rendell JM, Diamond PR, Shuttleworth C, Brett D, Amit BH, McShane R, Hamadi L, Hawton K, Cipriani A. Ketamine and other glutamate receptor modulators for depression in bipolar disorder in adults. Cochrane Database Syst Rev 2015:CD011611. [PMID: 26415966 DOI: 10.1002/14651858.cd011611.pub2] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND There is emerging evidence that glutamatergic system dysfunction might play an important role in the pathophysiology of bipolar depression. This review focuses on the use of glutamate receptor modulators for depression in bipolar disorder. OBJECTIVES 1. To assess the effects of ketamine and other glutamate receptor modulators in alleviating the acute symptoms of depression in people with bipolar disorder.2. To review the acceptability of ketamine and other glutamate receptor modulators in people with bipolar disorder who are experiencing acute depression symptoms. SEARCH METHODS We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR, to 9 January 2015). This register includes relevant randomised controlled trials (RCTs) from: the Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). We cross-checked reference lists of relevant papers and systematic reviews. We did not apply any restrictions to date, language or publication status. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing ketamine, memantine, or other glutamate receptor modulators with other active psychotropic drugs or saline placebo in adults with bipolar depression. DATA COLLECTION AND ANALYSIS At least two review authors independently selected studies for inclusion, assessed trial quality and extracted data. Primary outcomes for this review were response rate and adverse events. Secondary outcomes included remission rate, depression severity change scores, suicidality, cognition, quality of life, and dropout rate. We contacted study authors for additional information. MAIN RESULTS Five studies (329 participants) were included in this review. All included studies were placebo-controlled and two-armed, and the glutamate receptor modulators - ketamine (two trials), memantine (two trials), and cytidine (one trial) - were used as add-on drugs to mood stabilisers. The treatment period ranged from a single intravenous administration (all ketamine studies), to repeated administration for memantine and cytidine (8 to 12 weeks, and 12 weeks, respectively). Three of the studies took place in the USA, one in Taiwan, and in one, the location was unclear. The majority (70.5%) of participants were from Taiwan. All participants had a primary diagnosis of bipolar disorder, according to the DSM-IV or DSM-IV-TR, and were in a current depressive phase. The severity of depression was at least moderate in all but one study.Among all glutamate receptor modulators included in this review, only ketamine appeared to be more efficacious than placebo 24 hours after the infusion for the primary outcome, response rate (odds ratio (OR) 11.61, 95% confidence interval (CI) 1.25 to 107.74; P = 0.03; I² = 0%, 2 studies, 33 participants). This evidence was rated as low quality. The statistically significant difference disappeared at three days, but the mean estimate still favoured ketamine (OR 8.24, 95% CI 0.84 to 80.61; 2 studies, 33 participants; very low quality evidence). We found no difference in response between ketamine and placebo at one week (OR 4.00, 95% CI 0.33 to 48.66; P = 0.28, 1 study; 18 participants; very low quality evidence).There was no significant difference between memantine and placebo in response rate one week after treatment (OR 1.08, 95% CI 0.06 to 19.05; P = 0.96, 1 study, 29 participants), two weeks (OR 4.88, 95% CI 0.78 to 30.29; P = 0.09, 1 study, 29 participants), four weeks (OR 5.33, 95% CI 1.02 to 27.76; P = 0.05, 1 study, 29 participants), or at three months (OR, 1.66, 95% CI 0.69 to 4.03; P = 0.26, I² = 36%, 2 studies, 261 participants). These findings were based on very low quality evidence.There was no significant difference between cytidine and placebo in response rate at three months (OR, 1.13, 95% CI 0.30 to 4.24; P = 0.86, 1 study, 35 participants; very low quality evidence).For the secondary outcome of remission, no significant differences were found between ketamine and placebo, nor between memantine and placebo. For the secondary outcome of change scores from baseline on depression scales, ketamine was more effective than placebo at 24 hours (MD -11.81, 95% CI -20.01 to -3.61; P = 0.005, 2 studies, 32 participants) but not at one or two weeks after treatment. There was no difference between memantine and placebo for this outcome.We found no significant differences in terms of adverse events between placebo and ketamine, memantine, or cytidine. There were no differences between ketamine and placebo, memantine and placebo, or cytidine and placebo in total dropouts. No data were available on dropouts due to adverse effects for ketamine or cytidine; but no difference was found between memantine and placebo. AUTHORS' CONCLUSIONS Reliable conclusions from this review are severely limited by the small amount of data usable for analysis. The body of evidence about glutamate receptor modulators in bipolar disorder is even smaller than that which is available for unipolar depression. Overall, we found limited evidence in favour of a single intravenous dose of ketamine (as add-on therapy to mood stabilisers) over placebo in terms of response rate up to 24 hours; ketamine did not show any better efficacy in terms of remission in bipolar depression. Even though ketamine has the potential to have a rapid and transient antidepressant effect, the efficacy of a single intravenous dose may be limited. Ketamine's psychotomimetic effects could compromise study blinding; this is a particular issue for this review as no included study used an active comparator, and so we cannot rule out the potential bias introduced by inadequate blinding procedures.We did not find conclusive evidence on adverse events with ketamine. To draw more robust conclusions, further RCTs (with adequate blinding) are needed to explore different modes of administration of ketamine and to study different methods of sustaining antidepressant response, such as repeated administrations. There was not enough evidence to draw meaningful conclusions for the remaining two glutamate receptor modulators (memantine and cytidine). This review is limited not only by completeness of evidence, but also by the low to very low quality of the available evidence.
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Affiliation(s)
- Tayla L McCloud
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
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Caddy C, Amit BH, McCloud TL, Rendell JM, Furukawa TA, McShane R, Hawton K, Cipriani A. Ketamine and other glutamate receptor modulators for depression in adults. Cochrane Database Syst Rev 2015:CD011612. [PMID: 26395901 DOI: 10.1002/14651858.cd011612.pub2] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Considering the ample evidence of involvement of the glutamate system in the pathophysiology of depression, pre-clinical and clinical studies have been conducted to assess the antidepressant efficacy of glutamate inhibition, and glutamate receptor modulators in particular. This review focuses on the use of glutamate receptor modulators in unipolar depression. OBJECTIVES To assess the effects - and review the acceptability - of ketamine and other glutamate receptor modulators in comparison to placebo (or saline placebo), other pharmacologically active agents, or electroconvulsive therapy (ECT) in alleviating the acute symptoms of depression in people with unipolar major depressive disorder. SEARCH METHODS We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR, to 9 January 2015). This register includes relevant randomised controlled trials (RCTs) from: the Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). We did not apply any restrictions to date, language or publication status. SELECTION CRITERIA Double- or single-blind RCTs comparing ketamine, memantine, or other glutamate receptor modulators with placebo (or saline placebo), other active psychotropic drugs, or electroconvulsive therapy (ECT) in adults with unipolar major depression. DATA COLLECTION AND ANALYSIS Three review authors independently identified studies, assessed trial quality and extracted data. The primary outcomes for this review were response rate and adverse events. MAIN RESULTS We included 25 studies (1242 participants) on ketamine (9 trials), memantine (3), AZD6765 (3), D-cycloserine (2), Org26576 (2), atomoxetine (1), CP-101,606 (1), MK-0657 (1), N-acetylcysteine (1), riluzole (1) and sarcosine (1). Twenty-one studies were placebo-controlled and the majority were two-arm studies (23 out of 25). Twenty-two studies defined an inclusion criteria specifying the severity of depression; 11 specified at least moderate depression; eight, severe depression; and the remaining three, mild-moderate depression. Nine studies recruited only treatment-resistant patients.We rated the risk of bias as low or unclear for most domains, though lack of detail regarding masking of treatment in the studies reduced our certainty in the effect for all outcomes. We rated three studies as having high risk for selective outcome reporting. Many trials did not provide information on all the prespecified outcomes and we found no data, or very limited data, on very important issues like suicidality, cognition, quality of life, costs to healthcare services and dropouts due to lack of efficacy.Among all glutamate receptor modulators, only ketamine (administered intravenously) proved to be more efficacious than placebo, though the quality of evidence was limited by risk of bias and small sample sizes. There was low quality evidence that treatment with ketamine increased the likelihood of response after 24 hours (odds ratio (OR) 10.77, 95% confidence interval (CI) 2.00 to 58.00; 3 RCTs, 56 participants), 72 hours (OR 12.59, 95% CI 2.38 to 66.73; 3 RCTs, 56 participants), and one week (OR 2.58, 95% CI 1.08 to 6.16; 4 RCTs, 131 participants). The effect of ketamine was even less certain at two weeks, as data were available from only one trial (OR 0.93, 95% CI 0.31 to 2.83; 51 participants, low quality evidence). This was consistent across all efficacy outcomes. Ketamine caused more confusion and emotional blunting compared to placebo. There was insufficient evidence to determine if this increased the likelihood of leaving the study early (OR 1.90, 95% CI 0.43 to 8.47; 5 RCTs, 139 participants, low quality evidence).One RCT with 72 participants reported higher numbers of responders on ketamine than midazolam at 24 hours (OR 0.36, 95% CI 0.14 to 0.58), 72 hours (OR 0.37, 95% CI 0.16 to 0.59), and one week (OR 0.29, 95% CI 0.08 to 0.49). However, midazolam was better tolerated than ketamine in terms of blurred vision, dizziness, general malaise and nausea/vomiting at 24 hours post-infusion. The evidence contributing to these outcomes was of low quality.We found better efficacy of sarcosine over citalopram at four weeks (OR 6.93, 95% CI 1.53 to 31.38; 1 study, 40 participants), but not at two weeks (OR: 8.14, 95% CI 0.88 to 75.48); fewer participants in the sarcosine group experienced adverse events (OR 0.04, 95% CI 0.00 to 0.68; P = 0.03, 1 study, 40 participants). This was based on low quality evidence. No significant results were found for the remaining glutamate receptor modulators.In one study with 18 participants, ketamine was more effective than ECT at 24 hours (OR 28.00, 95% CI 2.07 to 379.25) and 72 hours (OR 12.25, 95% CI 1.33 to 113.06), but not at one week (OR 3.35, 95% CI 0.12 to 93.83), or two weeks (OR 3.35, 95% CI 0.12 to 93.83). No differences in terms of adverse events were found between ketamine and ECT, however the only adverse events reported were blood pressure and heart rate. This study was rated as very low quality. AUTHORS' CONCLUSIONS We found limited evidence for ketamine's efficacy over placebo at time points up to one week in terms of the primary outcome, response rate. The effects were less certain at two weeks post-treatment. No significant results were found for the remaining ten glutamate receptor modulators, except for sarcosine being more effective than citalopram at four weeks. In terms of adverse events, the only significant differences in favour of placebo over ketamine were in regards to confusion and emotional blunting. Despite the promising nature of these preliminary results, our confidence in the evidence was limited by risk of bias and the small number of participants. Many trials did not provide information on all the prespecified outcomes and we found no data, or very limited data, on very important issues like suicidality, cognition, quality of life, costs to healthcare services and dropouts due to lack of efficacy.All included studies administered ketamine intravenously, which can pose practical problems in clinical practice. Very few trials were included in the meta-analyses for each comparison; the majority of comparisons contained only one study. Further RCTs (with adequate blinding) are needed to explore different modes of administration of ketamine with longer follow-up, which test the comparative efficacy of ketamine and the efficacy of repeated administrations.
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Affiliation(s)
- Caroline Caddy
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK, OX3 7JX
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Rendell JM, Shuttleworth C, Jochim J, Diamond PR, Brett D, Amit BH, Hawton K, McShane R, Cipriani A. Ketamine and other glutamate receptor modulators for depression in bipolar disorder in adults. Cochrane Database Syst Rev 2015. [DOI: 10.1002/14651858.cd011611] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Harrison JK, Fearon P, Noel-Storr AH, McShane R, Stott DJ, Quinn TJ. Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) for the diagnosis of dementia within a secondary care setting. Cochrane Database Syst Rev 2015:CD010772. [PMID: 25754745 DOI: 10.1002/14651858.cd010772.pub2] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The diagnosis of dementia relies on the presence of new-onset cognitive impairment affecting an individual's functioning and activities of daily living. The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) is a questionnaire instrument, completed by a suitable 'informant' who knows the patient well, designed to assess change in functional performance secondary to cognitive change; it is used as a tool to identifying those who may have dementia.In secondary care there are two specific instances where patients may be assessed for the presence of dementia. These are in the general acute hospital setting, where opportunistic screening may be undertaken, or in specialist memory services where individuals have been referred due to perceived cognitive problems. To ensure an instrument is suitable for diagnostic use in these settings, its test accuracy must be established. OBJECTIVES To determine the diagnostic accuracy of the informant-based questionnaire IQCODE, for detection of all-cause (undifferentiated) dementia in adults presenting to secondary-care services. SEARCH METHODS We searched the following sources on the 28th of January 2013: ALOIS (Cochrane Dementia and Cognitive Improvement Group), MEDLINE (Ovid SP), EMBASE (Ovid SP), PsycINFO (Ovid SP), BIOSIS Previews (Thomson Reuters Web of Science), Web of Science Core Collection (includes Conference Proceedings Citation Index) (Thomson Reuters Web of Science), CINAHL (EBSCOhost) and LILACS (BIREME). We also searched sources specific to diagnostic test accuracy: MEDION (Universities of Maastricht and Leuven); DARE (Database of Abstracts of Reviews of Effects - via the Cochrane Library); HTA Database (Health Technology Assessment Database via the Cochrane Library) and ARIF (Birmingham University). We also checked reference lists of relevant studies and reviews, used searches of known relevant studies in PubMed to track related articles, and contacted research groups conducting work on IQCODE for dementia diagnosis to try to find additional studies. We developed a sensitive search strategy; search terms were designed to cover key concepts using several different approaches run in parallel and included terms relating to cognitive tests, cognitive screening and dementia. We used standardised database subject headings such as MeSH terms (in MEDLINE) and other standardised headings (controlled vocabulary) in other databases, as appropriate. SELECTION CRITERIA We selected those studies performed in secondary-care settings, which included (not necessarily exclusively) IQCODE to assess for the presence of dementia and where dementia diagnosis was confirmed with clinical assessment. For the 'secondary care' setting we included all studies which assessed patients in hospital (e.g. acute unscheduled admissions, referrals to specialist geriatric assessment services etc.) and those referred for specialist 'memory' assessment, typically in psychogeriatric services. DATA COLLECTION AND ANALYSIS We screened all titles generated by electronic database searches, and reviewed abstracts of all potentially relevant studies. Two independent assessors checked full papers for eligibility and extracted data. We determined quality assessment (risk of bias and applicability) using the QUADAS-2 tool, and reporting quality using the STARD tool. MAIN RESULTS From 72 papers describing IQCODE test accuracy, we included 13 papers, representing data from 2745 individuals (n = 1413 (51%) with dementia). Pooled analysis of all studies using data presented closest to a cut-off of 3.3 indicated that sensitivity was 0.91 (95% CI 0.86 to 0.94); specificity 0.66 (95% CI 0.56 to 0.75); the positive likelihood ratio was 2.7 (95% CI 2.0 to 3.6) and the negative likelihood ratio was 0.14 (95% CI 0.09 to 0.22).There was a statistically significant difference in test accuracy between the general hospital setting and the specialist memory setting (P = 0.019), suggesting that IQCODE performs better in a 'general' setting.We found no significant differences in the test accuracy of the short (16-item) versus the 26-item IQCODE, or in the language of administration.There was significant heterogeneity in the included studies, including a highly varied prevalence of dementia (10.5% to 87.4%). Across the included papers there was substantial potential for bias, particularly around sampling of included participants and selection criteria, which may limit generalisability. There was also evidence of suboptimal reporting, particularly around disease severity and handling indeterminate results, which are important if considering use in clinical practice. AUTHORS' CONCLUSIONS The IQCODE can be used to identify older adults in the general hospital setting who are at risk of dementia and require specialist assessment; it is useful specifically for ruling out those without evidence of cognitive decline. The language of administration did not affect test accuracy, which supports the cross-cultural use of the tool. These findings are qualified by the significant heterogeneity, the potential for bias and suboptimal reporting found in the included studies.
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Affiliation(s)
- Jennifer K Harrison
- Department of Cardiovascular Sciences, University of Leicester, Leicester Royal Infirmary, Leicester, UK, LE1 5WW
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Zhang S, Smailagic N, Hyde C, Noel‐Storr AH, Takwoingi Y, McShane R, Feng J. (11)C-PIB-PET for the early diagnosis of Alzheimer's disease dementia and other dementias in people with mild cognitive impairment (MCI). Cochrane Database Syst Rev 2014; 2014:CD010386. [PMID: 25052054 PMCID: PMC6464750 DOI: 10.1002/14651858.cd010386.pub2] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND According to the latest revised National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association (now known as the Alzheimer's Association) (NINCDS-ADRDA) diagnostic criteria for Alzheimer's disease dementia, the confidence in diagnosing mild cognitive impairment (MCI) due to Alzheimer's disease dementia is raised with the application of imaging biomarkers. These tests, added to core clinical criteria, might increase the sensitivity or specificity of a testing strategy. However, the accuracy of biomarkers in the diagnosis of Alzheimer's disease dementia and other dementias has not yet been systematically evaluated. A formal systematic evaluation of the sensitivity, specificity, and other properties of positron emission tomography (PET) imaging with the (11)C-labelled Pittsburgh Compound-B ((11)C-PIB) ligand was performed. OBJECTIVES To determine the diagnostic accuracy of the (11)C- PIB-PET scan for detecting participants with MCI at baseline who will clinically convert to Alzheimer's disease dementia or other forms of dementia over a period of time. SEARCH METHODS The most recent search for this review was performed on 12 January 2013. We searched MEDLINE (OvidSP), EMBASE (OvidSP), BIOSIS Previews (ISI Web of Knowledge), Web of Science and Conference Proceedings (ISI Web of Knowledge), PsycINFO (OvidSP), and LILACS (BIREME). We also requested a search of the Cochrane Register of Diagnostic Test Accuracy Studies (managed by the Cochrane Renal Group).No language or date restrictions were applied to the electronic searches and methodological filters were not used so as to maximise sensitivity. SELECTION CRITERIA We selected studies that had prospectively defined cohorts with any accepted definition of MCI with baseline (11)C-PIB-PET scan. In addition, we only selected studies that applied a reference standard for Alzheimer's dementia diagnosis for example NINCDS-ADRDA or Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) criteria. DATA COLLECTION AND ANALYSIS We screened all titles generated by electronic database searches. Two review authors independently assessed the abstracts of all potentially relevant studies. The identified full papers were assessed for eligibility and data were extracted to create two by two tables. Two independent assessors performed quality assessment using the QUADAS 2 tool. We used the hierarchical summary receiver operating characteristic (ROC) model to produce a summary ROC curve. MAIN RESULTS Conversion from MCI to Alzheimer's disease dementia was evaluated in nine studies. The quality of the evidence was limited. Of the 274 participants included in the meta-analysis, 112 developed Alzheimer's dementia. Based on the nine included studies, the median proportion converting was 34%. The studies varied markedly in how the PIB scans were done and interpreted.The sensitivities were between 83% and 100% while the specificities were between 46% and 88%. Because of the variation in thresholds and measures of (11)C-PIB amyloid retention, we did not calculate summary sensitivity and specificity. Although subject to considerable uncertainty, to illustrate the potential strengths and weaknesses of (11)C-PIB-PET scans we estimated from the fitted summary ROC curve that the sensitivity was 96% (95% confidence interval (CI) 87 to 99) at the included study median specificity of 58%. This equated to a positive likelihood ratio of 2.3 and a negative likelihood ratio of 0.07. Assuming a typical conversion rate of MCI to Alzheimer's dementia of 34%, for every 100 PIB scans one person with a negative scan would progress and 28 with a positive scan would not actually progress to Alzheimer's dementia.There were limited data for formal investigation of heterogeneity. We performed two sensitivity analyses to assess the influence of type of reference standard and the use of a pre-specified threshold. There was no effect on our findings. AUTHORS' CONCLUSIONS Although the good sensitivity achieved in some included studies is promising for the value of (11)C-PIB-PET, given the heterogeneity in the conduct and interpretation of the test and the lack of defined thresholds for determination of test positivity, we cannot recommend its routine use in clinical practice.(11)C-PIB-PET biomarker is a high cost investigation, therefore it is important to clearly demonstrate its accuracy and standardise the process of the (11)C-PIB diagnostic modality prior to it being widely used.
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Affiliation(s)
- Shuo Zhang
- China Medical UniversityDepartment of Neurology, Shengjing Hospital36 Shanhao StreetShenyangLiaoningChina110004
| | - Nadja Smailagic
- University of CambridgeInstitute of Public HealthForvie SiteRobinson WayCambridgeUKCB2 0SR
| | - Chris Hyde
- University of Exeter Medical School, University of ExeterInstitute of Health ResearchVeysey BuildingSalmon Pool LaneExeterUKEX2 4SG
| | - Anna H Noel‐Storr
- University of OxfordRadcliffe Department of MedicineRoom 4401c (4th Floor)John Radcliffe Hospital, HeadingtonOxfordUKOX3 9DU
| | - Yemisi Takwoingi
- University of BirminghamPublic Health, Epidemiology and BiostatisticsEdgbastonBirminghamUKB15 2TT
| | - Rupert McShane
- University of OxfordRadcliffe Department of MedicineRoom 4401c (4th Floor)John Radcliffe Hospital, HeadingtonOxfordUKOX3 9DU
| | - Juan Feng
- Shengjing Hospital, China Medical UniversityDepartment of Neurology36 Shanhao StreetShenyangChina110004
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Noel-Storr AH, McCleery JM, Richard E, Ritchie CW, Flicker L, Cullum SJ, Davis D, Quinn TJ, Hyde C, Rutjes AWS, Smailagic N, Marcus S, Black S, Blennow K, Brayne C, Fiorivanti M, Johnson JK, Köpke S, Schneider LS, Simmons A, Mattsson N, Zetterberg H, Bossuyt PMM, Wilcock G, McShane R. Reporting standards for studies of diagnostic test accuracy in dementia: The STARDdem Initiative. Neurology 2014; 83:364-73. [PMID: 24944261 PMCID: PMC4115600 DOI: 10.1212/wnl.0000000000000621] [Citation(s) in RCA: 142] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2013] [Accepted: 04/07/2014] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To provide guidance on standards for reporting studies of diagnostic test accuracy for dementia disorders. METHODS An international consensus process on reporting standards in dementia and cognitive impairment (STARDdem) was established, focusing on studies presenting data from which sensitivity and specificity were reported or could be derived. A working group led the initiative through 4 rounds of consensus work, using a modified Delphi process and culminating in a face-to-face consensus meeting in October 2012. The aim of this process was to agree on how best to supplement the generic standards of the STARD statement to enhance their utility and encourage their use in dementia research. RESULTS More than 200 comments were received during the wider consultation rounds. The areas at most risk of inadequate reporting were identified and a set of dementia-specific recommendations to supplement the STARD guidance were developed, including better reporting of patient selection, the reference standard used, avoidance of circularity, and reporting of test-retest reliability. CONCLUSION STARDdem is an implementation of the STARD statement in which the original checklist is elaborated and supplemented with guidance pertinent to studies of cognitive disorders. Its adoption is expected to increase transparency, enable more effective evaluation of diagnostic tests in Alzheimer disease and dementia, contribute to greater adherence to methodologic standards, and advance the development of Alzheimer biomarkers.
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Affiliation(s)
| | | | - Edo Richard
- Authors' affiliations are listed at the end of the article
| | | | - Leon Flicker
- Authors' affiliations are listed at the end of the article
| | - Sarah J Cullum
- Authors' affiliations are listed at the end of the article
| | - Daniel Davis
- Authors' affiliations are listed at the end of the article
| | | | - Chris Hyde
- Authors' affiliations are listed at the end of the article
| | | | | | - Sue Marcus
- Authors' affiliations are listed at the end of the article
| | - Sandra Black
- Authors' affiliations are listed at the end of the article
| | - Kaj Blennow
- Authors' affiliations are listed at the end of the article
| | - Carol Brayne
- Authors' affiliations are listed at the end of the article
| | | | | | - Sascha Köpke
- Authors' affiliations are listed at the end of the article
| | | | - Andrew Simmons
- Authors' affiliations are listed at the end of the article
| | | | | | | | - Gordon Wilcock
- Authors' affiliations are listed at the end of the article
| | - Rupert McShane
- Authors' affiliations are listed at the end of the article.
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Harrison JK, Fearon P, Noel-Storr AH, McShane R, Stott DJ, Quinn TJ. Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) for the diagnosis of dementia within a general practice (primary care) setting. Cochrane Database Syst Rev 2014:CD010771. [PMID: 24990271 DOI: 10.1002/14651858.cd010771.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND The IQCODE (Informant Questionnaire for Cognitive Decline in the Elderly) is a commonly used questionnaire based tool that uses collateral information to assess for cognitive decline and dementia. Brief tools that can be used for dementia "screening" or "triage" may have particular utility in primary care / general practice healthcare settings but only if they have suitable test accuracy.A synthesis of the available data regarding IQCODE accuracy in a primary care setting should help inform cognitive assessment strategies for clinical practice; research and policy. OBJECTIVES We sought to describe the accuracy of IQCODE (the index test) against a clinical diagnosis of dementia (the reference standard). In this review we focus on those studies conducted in a primary care (general practice) setting. SEARCH METHODS A search was performed in the following sources on the 28th of January 2013: ALOIS (Cochrane Dementia and Cognitive Improvement Group), MEDLINE (Ovid SP), EMBASE (Ovid SP), PsycINFO (Ovid SP), BIOSIS (Ovid SP), ISI Web of Science and Conference Proceedings (ISI Web of Knowledge), CINHAL (EBSCOhost) and LILACs (BIREME). We also searched sources specific to diagnostic test accuracy: MEDION (Universities of Maastricht and Leuven); DARE (York University); HTA Database (Health Technology Assessments Database via The Cochrane Library) and ARIF (Birmingham University). We developed a sensitive search strategy; search terms were designed to cover key concepts using several different approaches run in parallel and included terms relating to cognitive tests, cognitive screening and dementia. We used standardized database subject headings such as MeSH terms (in MEDLINE) and other standardized headings (controlled vocabulary) in other databases, as appropriate. SELECTION CRITERIA We selected those studies performed in primary care settings, which included (not necessarily exclusively) IQCODE to assess for the presence of dementia and where dementia diagnosis was confirmed with clinical assessment. For the "primary care" setting, we included those healthcare settings where unselected patients, present for initial, non-specialist assessment of memory or non-memory related symptoms; often with a view to onward referral for more definitive assessment. DATA COLLECTION AND ANALYSIS We screened all titles generated by electronic database searches and abstracts of all potentially relevant studies were reviewed. Full papers were assessed for eligibility and data extracted by two independent assessors. Quality assessment (risk of bias and applicability) was determined using the QUADAS-2 tool. Reporting quality was determined using the STARDdem extension to the STARD tool. MAIN RESULTS From 71 papers describing IQCODE test accuracy, we included 1 paper, representing data from 230 individuals (n=16 [7%] with dementia). The paper described those patients consulting a primary care service who self-identified as Japanese-American. Dementia diagnosis was made using Benson & Cummings criteria and the IQCODE was recorded as part of a longer interview with the informant.IQCODE accuracy was assessed at various test thresholds, with a "trade-off" between sensitivity and specificity across these cutpoints. At an IQCODE threshold of 3.2 sensitivity: 100%, specificity: 76%; for IQCODE 3.7 sensitivity: 75%, specificity: 98%.Applying the QUADAS-2 assessments, the study was at high risk of bias in all categories. In particular degree of blinding was unclear and not all participants were included in the final analysis. AUTHORS' CONCLUSIONS It is not possible to give definitive guidance on the test accuracy of IQCODE for the diagnosis of dementia in a primary care setting based on the single study identified. We are surprised by the lack of research using the IQCODE in primary care as this is, arguably, the most appropriate setting for targeted case finding of those with undiagnosed dementia in order to maximise opportunities to intervene and provide support for the individual and their carers.
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Affiliation(s)
- Jennifer K Harrison
- Department of Cardiovascular Sciences, University of Leicester, Leicester Royal Infirmary, Leicester, UK, LE1 5WW
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McShane R. F5‐01‐03: RESEARCH EVIDENCE ABOUT DIAGNOSIS, PREVENTION, AND PHARMACEUTICAL INTERVENTIONS FOR ALZHEIMER DISEASE IS OVERSOLD. Alzheimers Dement 2014. [DOI: 10.1016/j.jalz.2014.04.460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Rupert McShane
- Cochrane Dementia and Cognitive Improvement GroupUniversity of Oxford, John Radcliffe HospitalOxfordUnited Kingdom
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Ritchie C, Smailagic N, Noel‐Storr AH, Takwoingi Y, Flicker L, Mason SE, McShane R. Plasma and cerebrospinal fluid amyloid beta for the diagnosis of Alzheimer's disease dementia and other dementias in people with mild cognitive impairment (MCI). Cochrane Database Syst Rev 2014; 2014:CD008782. [PMID: 24913723 PMCID: PMC6465069 DOI: 10.1002/14651858.cd008782.pub4] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND According to the latest revised National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association (now known as the Alzheimer's Association) (NINCDS-ADRDA) diagnostic criteria for Alzheimer's disease dementia of the National Institute on Aging and Alzheimer Association, the confidence in diagnosing mild cognitive impairment (MCI) due to Alzheimer's disease dementia is raised with the application of biomarkers based on measures in the cerebrospinal fluid (CSF) or imaging. These tests, added to core clinical criteria, might increase the sensitivity or specificity of a testing strategy. However, the accuracy of biomarkers in the diagnosis of Alzheimer's disease dementia and other dementias has not yet been systematically evaluated. A formal systematic evaluation of sensitivity, specificity, and other properties of plasma and CSF amyloid beta (Aß) biomarkers was performed. OBJECTIVES To determine the accuracy of plasma and CSF Aß levels for detecting those patients with MCI who would convert to Alzheimer's disease dementia or other forms of dementia over time. SEARCH METHODS The most recent search for this review was performed on 3 December 2012. We searched MEDLINE (OvidSP), EMBASE (OvidSP), BIOSIS Previews (ISI Web of Knowledge), Web of Science and Conference Proceedings (ISI Web of Knowledge), PsycINFO (OvidSP), and LILACS (BIREME). We also requested a search of the Cochrane Register of Diagnostic Test Accuracy Studies (managed by the Cochrane Renal Group).No language or date restrictions were applied to the electronic searches and methodological filters were not used so as to maximise sensitivity. SELECTION CRITERIA We selected those studies that had prospectively well defined cohorts with any accepted definition of cognitive decline, but no dementia, with baseline CSF or plasma Aß levels, or both, documented at or around the time the above diagnoses were made. We also included studies which looked at data from those cohorts retrospectively, and which contained sufficient data to construct two by two tables expressing plasma and CSF Aß biomarker results by disease status. Moreover, studies were only selected if they applied a reference standard for Alzheimer's dementia diagnosis, for example the NINCDS-ADRDA or Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria. DATA COLLECTION AND ANALYSIS We screened all titles generated by the electronic database searches. Two review authors independently assessed the abstracts of all potentially relevant studies. We assessed the identified full papers for eligibility and extracted data to create standard two by two tables. Two independent assessors performed quality assessment using the QUADAS-2 tool. Where data allowed, we derived estimates of sensitivity at fixed values of specificity from the model we fitted to produce the summary receiver operating characteristic (ROC) curve. MAIN RESULTS Alzheimer's disease dementia was evaluated in 14 studies using CSF Aß42. Of the 1349 participants included in the meta-analysis, 436 developed Alzheimer's dementia. Individual study estimates of sensitivity were between 36% and 100% while the specificities were between 29% and 91%. Because of the variation in assay thresholds, we did not estimate summary sensitivity and specificity. However, we derived estimates of sensitivity at fixed values of specificity from the model we fitted to produce the summary ROC curve. At the median specificity of 64%, the sensitivity was 81% (95% CI 72 to 87). This equated to a positive likelihood ratio (LR+) of 2.22 (95% CI 2.00 to 2.47) and a negative likelihood ratio (LR-) of 0.31 (95% CI 0.21 to 0.48).The accuracy of CSF Aß42 for all forms of dementia was evaluated in four studies. Of the 464 participants examined, 188 developed a form of dementia (Alzheimer's disease and other forms of dementia).The thresholds used were between 209 mg/ml and 512 ng/ml. The sensitivities were between 56% and 75% while the specificities were between 47% and 76%. At the median specificity of 75%, the sensitivity was estimated to be 63% (95% CI 22 to 91) from the meta-analytic model. This equated to a LR+ of 2.51 (95% CI 1.30 to 4.86) and a LR- of 0.50 (95% CI 0.16 to 1.51).The accuracy of CSF Aß42 for non-Alzheimer's disease dementia was evaluated in three studies. Of the 385 participants examined, 61 developed non-Alzheimer's disease dementia. Since there were very few studies and considerable variation between studies, the results were not meta-analysed. The sensitivities were between 8% and 63% while the specificities were between 35% and 67%.Only one study examined the accuracy of plasma Aß42 and the plasma Aß42/Aß40 ratio for Alzheimer's disease dementia. The sensitivity of 86% (95% CI 81 to 90) was the same for both tests while the specificities were 50% (95% CI 44 to 55) and 70% (95% CI 64 to 75) for plasma Aß42 and the plasma Aß42/Aß40 ratio respectively. Of the 565 participants examined, 245 developed Alzheimer's dementia and 87 non-Alzheimer's disease dementia.There was substantial heterogeneity between studies. The accuracy of Aß42 for the diagnosis of Alzheimer's disease dementia did not differ significantly (P = 0.8) between studies that pre-specified the threshold for determining test positivity (n = 6) and those that only determined the threshold at follow-up (n = 8). One study excluded a sample of MCI non-Alzheimer's disease dementia converters from their analysis. In sensitivity analyses, the exclusion of this study had no impact on our findings. The exclusion of eight studies (950 patients) that were considered at high (n = 3) or unclear (n = 5) risk of bias for the patient selection domain also made no difference to our findings. AUTHORS' CONCLUSIONS The proposed diagnostic criteria for prodromal dementia and MCI due to Alzheimer's disease, although still being debated, would be fulfilled where there is both core clinical and cognitive criteria and a single biomarker abnormality. From our review, the measure of abnormally low CSF Aß levels has very little diagnostic benefit with likelihood ratios suggesting only marginal clinical utility. The quality of reports was also poor, and thresholds and length of follow-up were inconsistent. We conclude that when applied to a population of patients with MCI, CSF Aß levels cannot be recommended as an accurate test for Alzheimer's disease.
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Affiliation(s)
| | - Nadja Smailagic
- University of CambridgeInstitute of Public HealthForvie SiteRobinson WayCambridgeUKCB2 0SR
| | - Anna H Noel‐Storr
- University of OxfordRadcliffe Department of MedicineRoom 4401c (4th Floor)John Radcliffe Hospital, HeadingtonOxfordUKOX3 9DU
| | - Yemisi Takwoingi
- University of BirminghamPublic Health, Epidemiology and BiostatisticsEdgbastonBirminghamUKB15 2TT
| | - Leon Flicker
- University of Western AustraliaWestern Australian Centre for Health & Ageing ‐ WACHACrawleyPerthWestern AustraliaAustralia6014
| | | | - Rupert McShane
- University of OxfordRadcliffe Department of MedicineRoom 4401c (4th Floor)John Radcliffe Hospital, HeadingtonOxfordUKOX3 9DU
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